1. health and fitness
2. therapy

Ethics and values in psychotherapy
The role of ethics and values within psychotherapy is an important and
sometimes contentious one; yet discussion has often taken place in
isolation from traditional ethical theories. However, traditional ethical
theory does not address questions of practice in psychotherapy.
Covering the intellectual and social context, the means and ends of
therapy and the role of therapy in society, this book draws upon
philosophy’s understanding of ethics and the psychological literature to
focus on the role of the therapist as ethicist, and examines how the ethical
convictions of both therapists and clients contribute to the practical
process of therapy. Ethics and Values in Psychotherapy will be welcomed by
all those who have an interest in the increasingly important issue of
professional ethics and values within psychotherapy.
Alan C.Tjeltveit, who has a Ph.D. in clinical psychology, completed a
clinical internship at the University of Minnesota. A psychotherapist
since 1978, he has taught undergraduate and graduate students,
contributed articles to Clinical Psychology Review and Psychotherapy and
chaired a psychological association ethics committee. He is Associate
Professor of Psychology at Muhlenberg College in Allentown,
Pennsylvania, where he maintains a clinical practice.
Ethics and values in
psychotherapy
Alan C.Tjeltveit
London and New York
First published 1999
by Routledge
11 New Fetter Lane, London EC4P 4EE
This edition published in the Taylor & Francis e-Library, 2005.
“To purchase your own copy of this or any of Taylor & Francis or Routledge’s
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Simultaneously published in the USA and Canada
by Routledge
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© 1999 Alan C.Tjeltveit
All rights reserved. No part of this book may be reprinted or
reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter
invented, including photocopying and recording, or in any
information storage or retrieval system, without permission in
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A catalogue record for this book is available from the British
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To Maria
Contents
Preface
PART I Developing a better understanding of the ethical
character of psychotherapy
vii
1
1
Introduction
2
Ethics: challenging, inescapable questions
16
3
Psychotherapists as ethicists: engaging in difficult,
essential tasks
33
PART II Intellectual tools for examining values and ethical
theory in therapy: assumptions and criteria for analysis
and decision-making
2
46
4
The spectrum of ethical theories in psychotherapy
47
5
Unpacking diverse understandings of “values”
78
PART III Ethical dimensions of the contexts of psychotherapy
100
6
The intellectual contexts of psychotherapy: ethics
and science
101
7
The social contexts of psychotherapy: clinical
practice and business
125
PART IV Change in psychotherapy: ethical facets
147
8
Ethical dimensions of the techniques, strategies, and
processes of therapy: which means to therapeutic
ends?
148
9
Ethical dimensions of the goals and outcome of
therapy: therapy as means to which (ethics-laden)
ends?
181
PART V Implications
10
Rethinking psychotherapy’s location in a society:
public philosophy and social and therapeutic
contracts
221
222
vi
11
Profession and professional ethics
245
12
Shaping the ethical character of psychotherapy:
inevitable choices, better choices
259
Notes
278
References
284
Index
321
Preface
Murder mysteries accompany me on long trips. I like people who find
clues that others miss, who patiently put together a case, who pay
attention to all the important evidence, who look beyond the obvious,
who think clearly and well.
To think well about the ethical character of psychotherapy we need, I
think, to be like those sleuths. Although the mystery of therapy has to do
with positive human change, not murder, complexities abound, and the
skills of the detective can help us to understand and make good decisions
about ethics and values in psychotherapy.
Abundant clues await those who want to think more deeply than
“Therapy is not value-free.” New evidence from a variety of sources can
be used by people who want to explore how—for good and ill—the
ethical convictions of therapist, client, and culture invigorate therapy.
The empirical finding that therapists influence client values, research on
therapy in general, the increasingly sophisticated psychology of moral
development, the retrieval and application to psychology of Continental
philosophical traditions, cross-cultural psychological investigations, and
the careful historical work that is reshaping our understanding of
psychology and psychotherapy all provide evidence that is essential to a
satisfactory solution to the mystery of the role of values in therapy.
Emerging developments in ethics provide crucial clues as well: the rise
of a transdisciplinary bioethics that links together academic philosophy
and the clinical setting, ethical analyses of psychotherapy, evolving
standards of professional ethics, the vigor and creativity of feminist
ethics, the development of revivified and psychologically nuanced forms
of virtue ethics, cross-cultural ethical studies, and analyses of how culture
shapes ethics and therapy. Finally, careful work on the definition of
“values” and the increasing involvement in therapy of those who pay for
therapy (e.g. insurance companies, governments, and managed care
organizations) provide us with new perspectives from which to consider
the evidence.
To make progress in unraveling the mystery of the ethical character of
therapy, we need to move, I think, beyond obvious solutions and
think deeply about those various strands of evidence. Accordingly, this
book joins together what many would sunder—the practical and the
viii
theoretical. Psychotherapists and others who dislike the philosophical
may thus think it too theoretical; philosophers, in turn, may find it too
practical and insufficiently philosophical. But I think it is in the balance
of the practical and the theoretical that we can discover the best answers,
even if those answers fall far short of perfection or certainty.
My interest in ethics, values, and psychotherapy began in graduate
school. A seminar with Neil Clark Warren and David Allan Hubbard
played a pivotal role. I am grateful for their assistance and
encouragement, and that given to me at the time (and since) by Hendrika
Vande Kemp, H.Newton Malony, Lewis Smedes, Don Browning, and
Paul Meehl. My ideas evolved through five years of full-time clinical
practice, work on a hospital Bioethics Consultation Team, seven years of
service on a psychological association ethics committee, teaching and
supervising undergraduate and graduate students in psychology
(including a seminar on Values and Psychotherapy I team-taught with
C.Stephen Evans), and conducting empirical research on values in
collaboration with my students. I have benefited from working in a
scientifically-oriented department that shares a cozy building with an
excellent philosophy department. Teaching in a liberal arts college
encourages me to think from a variety of disciplinary perspectives and
reinforces my belief in the importance of the liberal arts, of scholarly
breadth and integration. Active participation in conferences and
numerous e-mail exchanges with an informal group of researchers
investigating the role of values in therapy has also been very helpful. And
personal support and increasing theoretical and philosophical
sophistication have been the fruits of my involvement with the American
Psychological Association’s Division of Theoretical and Philosophical
Psychology.
Muhlenberg College has supported me with several summer research
grants and a year-long sabbatical to work on this project, for which I am
deeply grateful. I am also thankful to the librarians at Muhlenberg and
Abbott Northwestern Hospital for faithfully tracking down books and
journal articles in accord with my repeated requests.
I am particularly grateful to Sam Knapp, who read the entire
manuscript, and to Christine Sistare, Daniel Wilson, Larry Hass, Ed
Lundeen, Stanton Jones, Deborah Heggie, George Howard, Isaac
Prilleltensky, Gary Schoener, students in several classes, and anonymous
reviewers, who read portions of it. The usual caveat applies: I have
benefited from their wise counsel, but have sometimes chosen to
disregard it. I am also grateful to my therapy clients and my students,
from whom I have learned much. Finally, I am most thankful to my wife,
Maria, whose arrival in my life—at the beginning of the sabbatical
supposedly devoted entirely to writing this book—proved to be a great
distraction. And my greatest delight.
Part I
Developing a better understanding of
the ethical character of psychotherapy
1
Introduction
Psychotherapy, once viewed as value-free, is now widely acknowledged
to be value-laden. But what does it mean that psychotherapy is valueladen? In what ways is it laden? With which values? Can those values be
eliminated from therapy? If not, with which values ought it be laden? Put
another way, how can we best understand and address the ethical
dimensions of psychotherapy?
When a client comes to a psychotherapist with complaints of sadness
and meaninglessness and says “I feel absolutely horrible. What should I
do?” the therapist’s response invariably represents some ethical position;
it is value-laden. As Bergin put it, “Values are an inevitable and
pervasive part of psychotherapy” (Bergin 1980b: 97).
Challenges immediately confront such assertions. But when we face
them squarely and thoroughly, we can better understand the complexity
of psychotherapy’s ethical dimensions and the field can move beyond its
present impasse in understanding and addressing values in therapy.
Setting the stage
The challenges to the claim that psychotherapy is invariably value-laden
have much validity. Because they raise key questions, highlight some of
the debate to come, begin to clarify the reasons for the current impasse,
and help to clarify the central thrust of this book, six of those challenges
warrant brief consideration at the outset.
Psychotherapy is inconsequentially value-laden
Some psychotherapists deny that all therapy is value-laden. They hold
that some or most therapy is not; therefore, therapists rarely function as
ethicists. Although acknowledging that some therapist responses to the
sad client’s entreaty would clearly be value-laden (e.g. “You should
honor the sacred commitment you made on your wedding day, return to
your spouse, and begin paying some attention to your obligations to your
children”), they argue that other responses are ethically “neutral”
INTRODUCTION 3
(e.g.‘“Sounds like you’re really feeling sad. How long has this been going
on?”). This challenge thus raises some key questions that need to be
addressed to develop a full-fledged understanding of values in therapy:
to what extent is therapy value-laden? doesn’t value-free therapy (or
minimally value-laden therapy) remain an important ideal, albeit one not
achieved by inexperienced or inexpert therapists? Another issue will also
need to be considered: are there implicit values in therapy (even in
“neutral” responses in therapy), values that are rarely examined, values
perhaps subtly conveyed in the language, symbols, stories, and
institutions of psychotherapy, values perhaps so widely or deeply held in
a particular culture that they remain unnoticed?
Psychotherapy involves only mental health values
Other psychotherapists acknowledge that therapy is value-laden but
assert that it is (or ought to be) laden primarily with values that
contribute to therapeutic goals, that is, with values that contribute to
improved psychological functioning. Strupp, for instance, distinguishes
between essential therapeutic values (e.g. “People have the right to
personal freedom and independence”), which are essential to the
therapeutic endeavor, and optional and idiosyncratic values, which are
not (Strupp 1980:397–8). If psychotherapy is viewed in terms of essential
therapeutic values and therapists practice in accord with them, he
argues, “the issue of indoctrination or the alleged dangers of a laissezfaire stance are largely inconsequential” (Strupp 1980:400). Accepting
Strupp’s distinction raises two questions: which values are “essential
therapeutic values”? to what extent do therapists’ optional values (e.g.
their deepest convictions about human flourishing) influence the
outcome of therapy?
This challenge raises a vitally important, very complex issue: the
relationship between values and the goals of therapy. To make my
position clear (arguments will be developed later), I propose the
following thesis: a central reason for the inevitability of therapy’s valueladenness is that all therapy involves value-laden goals. As Bergin notes, “as
an applied field, psychotherapy is directed toward practical goals that are
selected in value terms” (Bergin 1980b: 97). So, for instance, if we want to
understand “essential therapeutic values,” we need to examine
therapeutic goals very closely.
This raises some key questions: what is the goal of psychotherapy? if it
is “mental health,” or “improved” or “ideal” psychological functioning,
what do those terms mean? to which values or ethical positions (if any)
does endorsement of a therapeutic goal commit a therapist?
Discussion of therapy goals is often difficult, for several reasons: the
terms therapists use to express therapy goals (e.g. “mental health,”
“behavior change,” and “self-actualization”) vary widely. Therapists use
4 ETHICS AND VALUES IN PSYCHOTHERAPY
the same terms in significantly different ways. And many therapists
individualize the goals they set for clients—so goals in a particular
therapeutic relationship depend on the nature of the problem, the client’s
stated goals, client characteristics (including client personality and
personal and social strengths), financial considerations (character
reconstruction is rarely a goal for a managed care client of modest
means), the stage of therapy, and so forth. As an example of the second
difficulty, two significantly different meanings of mental health (and
related terms) need to be distinguished: freedom from serious
psychological dysfunction, and positive mental health. In general, greater
consensus has developed regarding values tied to the former than to the
latter. For instance, in working with a severely depressed client a
therapist may establish the therapeutic goal of decreased depression.
That goal involves a value (“It is good to be free from severe depression”)
about which there is wide agreement in society. However, mental health
professionals disagree, at times sharply, about the meaning of mental
health understood as ideal human functioning. In 1958, Jahoda sought—
without success—to find agreement among therapists about the meaning
of “positive mental health.” And it is likely that there is even less
agreement now.
Introducing different perspectives on mental health (including those of
non-therapists) makes even more complex the tasks of defining concepts
of mental health1 and clarifying the values (if any) tied to such
definitions. Stiles, Shapiro, and Barkham suggest that, “stakeholders—
individuals or groups, therapists, clients, families, or others in society—
may have different perspectives, interests, and values regarding
psychotherapeutic outcomes” (Stiles, Shapiro, and Barkham 1993:116).2
Adopting cross-cultural perspectives makes clarifying, evaluating, and
justifying the values tied to therapeutic goals (and thus to therapy itself)
even more daunting, because some argue that traditional therapy goals
reflect Western cultural values. And so, those goals may or may not be
transportable to other cultural settings. Any claims that they represent the
essence of psychotherapy and ideal human functioning may thus need
rethinking. To give one example, consider autonomy, a value Strupp
(1980) considers an essential therapeutic value and which 96 percent of
the US therapists surveyed by Jensen and Bergin endorsed as “important
for a positive, mentally healthy life-style” (Jensen and Bergin 1988:293).
Varma noted that in India “there is a greater degree of mutual
interdependence” than in the West. Thus, he argues:
it is questionable how far Western psychotherapy with its high
emphasis on autonomy and individual responsibility can be
prescribed for members of such a society; and accordingly what
modifications are required in the rules and practice of conventional
psychotherapy.
(Varma 1988:145)
INTRODUCTION 5
Western feminists (e.g. Adleman 1990; Ballou 1990; Feminist
Therapy Institute 1990; Lerman and Porter 1990) have also criticized
dominant values in therapy, challenging the sexist values implicit in
traditional therapies and codes of ethics.
These considerations raise several questions: with which values are
therapy goals laden? to what extent is it possible for therapists to free
clients from their presenting problems without also changing them in
directions valued by the therapist? how do various concepts of mental
health represent answers to classic ethical questions concerning what is
good, what is virtuous, and what is right? which therapy goals are best?
and why?
To sharpen the terms of the debate, let me state an assertion, a qualified
version of which I will defend in this book: any therapeutic goal held by
therapists, clients, or third parties (e.g. insurance companies or government
funding sources) represents a commitment (implicit or explicit, limited or
extensive) to some value(s) and some working ethical theory.
Some psychotherapists suggest that the problems of values in
psychotherapy goals can be solved by adopting, to the widest extent
possible, the consensus among therapists regarding essential therapeutic
values (while of course continuing to allow ample room for individual
differences among therapists regarding regarding nonessential
therapeutic values). This seems plausible. And I will argue that it is
essential, as a matter of public policy, that a society should develop some
measure of basic agreement about the goals of therapy (in part to justify
why insurance companies, managed care entities, governments, and
other third-party payers should continue to pay increasing amounts for
“mental health” coverage). But I will also argue that the articulation and
development of a consensus needs to occur much more explicitly, and
involve all stakeholders in therapy, not just third-party payers.
At a deeper level, however, those psychotherapists who rely solely on
consensus to define the goals of therapy may adopt a decidedly
conservative (“when it comes to therapy goals and values, therapists
should believe what our elders passed on to us”) and profoundly
problematic position. One of the marks of the scientist, indeed of any
well-educated person, is the ability to question received tradition and to
use reason and evidence to formulate an argument, either supporting or
rejecting a particular intellectual claim. The goals of therapy in particular,
and the whole set of questions having to do with ethics and values in
therapy in general, require this kind of rigorous intellectual scrutiny. The
fact that therapists do endorse certain values does not establish that those
values are best, are correct, or should be endorsed. That is, we cannot
move directly from a fact about an existing consensus to the claim that
those values should be adopted; we cannot move in any straightforward
way from assertions about what is to assertions about what ought to be.
Accordingly, whether or not there is a consensus (and the evidence is
mixed; see Consoli 1996; Haugen, Tyler, and Clark 1991; Jensen and
Bergin 1988; E.W.Kelly 1995a), we must still ask why therapy should be
6 ETHICS AND VALUES IN PSYCHOTHERAPY
devoted to a particular goal or goals, and not to other goals, and what
ethical justification (if any) can be provided for such goals.
From Strupp’s perspective, psychotherapists addressing such
questions face a dilemma: “We don’t know how to research the problem”
of values in therapy (Strupp 1980:397). While we should not
underestimate the difficulties of arriving at ethical knowledge, if
someone interpreted Strupp to mean we are unable to make any ethical
assertions, I would think that person unduly pessimistic.
Psychotherapists have, in fact, always answered ethical questions—by
drawing upon consensus, training, experts, experience, intuition, rational
arguments, science, and so forth. Furthermore, pessimism that paralyzes
efforts to reflect deeply about therapy’s valueladenness has contributed
substantially to the present impasse in the field of values and therapy.
While definitive solutions will likely remain elusive, I think progress can
occur in the ethical arena. The challenge is to determine the best, or the
best possible combination, of those approaches to address a particular
ethical question. Accordingly, in Chapters 4, 5, and elsewhere, I will
defend the thesis that it can be fruitful for therapists to think about ethical
convictions and ethical theory (e.g. to think about the reasons for holding certain
ethical convictions as opposed to others). From this thesis (which stands in
stark contrast to the philosophical stance adopted—at times after careful
reflection—by many in psychology) follows a second: since ethics and
values inevitably play a role in psychotherapy, therapists need to think well
about the ethical theory and values with which therapy is laden. In accord with
those theses, this book addresses how to think well (“how to research”)
the problems of ethics and values in therapy.
Clients alone should choose therapy values
Other critics of the idea that therapy is value-laden raise a (related)
challenge: therapists do not, and ought not to, determine goals or values
in therapy but, rather, simply serve the goals and values clients
themselves choose. This position could, of course, lead to the conclusion
that there are as many legitimate therapeutic goals (or notions of mental
health) and values as there are clients. While this position has
considerable intuitive appeal, and substantial merit, it faces several
intellectual challenges.
This position is not, finally, a claim that therapy is value-free, but an
argument that therapy involves, or should involve, a particular value or
set of values (e.g. the value that all client goals are good or acceptable,
that it is best or most good for clients to choose their own values, or that
it is wrong for therapists to impose their values on clients). It is thus not a
claim that therapy is value-free, but that therapy should be delimited to a
narrow range of values—those chosen by clients and those supporting
client choice of therapy goals. The argument is defensible, but it raises its
own set of questions: why should we adopt this position? how can its
“essential therapeutic values” be justified?
INTRODUCTION 7
A practical issue must also be faced. When third parties (government
agencies or corporations, acting directly or through insurance companies
or managed care entities) pay for therapy, they increasingly want a say in
determining therapy goals. Taxpayers and retirees may well wish to pay
only for therapy to reduce serious psychopathology. Government
funding (provided by taxpayers) and insurance companies (who serve
corporations, whose stock is often owned by pension funds, upon which
the elderly rely for their income) may thus limit their support for
psychotherapy. Accordingly, only the wealthy may be able to afford
therapy intended to reach any goal clients choose.
In addition, those arguing that clients alone appropriately choose
therapy goals must wrestle with the possibility that some clients might
choose therapy goals many would consider undesirable or unacceptable.
A client goal may conflict, for instance, with the “essential” therapeutic
value of client autonomy. Suppose a new client states, “I came to therapy
because I want to feel better. Now, I don’t want to change how I lead my
life, but I want you to make me feel better.” Or, “My goal for therapy is
for you to tell me what to do.” Few therapists would accept those client
goals, because they conflict with therapist values about proper therapy
goals, with values therapists believe necessary for the development of
ideal psychological functioning, or both.
The issue of how to handle other types of questionable client goals was
raised in connection with a case discussed by R.J.Kohlenberg (1974). In
accord with a male client’s wishes, Kohlenberg successfully decreased the
client’s behaviors associated with child molesting and increased his
sexual arousal to adult males. In a commentary on the case, Strupp (1974)
raised the question of whether, had the client sought treatment for his
ineffective prowling behavior (which meant little sexual contact with
young boys), Kohlenberg would have used assertiveness training to
increase the efficacy of the client’s prowling behavior, and thus increased
his sexual success with young boys. Strupp suggested that Kohlenberg’s
likely unwillingness to do so would have stemmed from Kohlenberg’s
and society’s values, which, in that instance, would have (appropriately)
superseded the client’s goal. Similarly, Garfield (1974) posed the question
of how Kohlenberg would have responded if the client’s goal had been
the elimination of the discomfort and stress he felt about being sexually
involved with boys, if the client had aspired to guilt-free pedophilia.
Garfield concludes that therapists must make a judgment about how
“desirable” client goals are. The comments of Garfield and Strupp suggest
that the doctrine, “Client goals are always to be pursued,” warrants at
least some qualification.
Finally, even when client goals are accepted, other values may also
be present in therapy, those tied to the means by which the client’s ends
are pursued. For instance, leaving aside practical considerations related
to the transmission of the HIV virus, therapist values may permit (or
encourage) the use of sexual surrogates to treat client sexual problems (the
elimination of which is an end endorsed by the client). But the client may
have moral objections to that particular means. To use Rokeach’s (1973)
8 ETHICS AND VALUES IN PSYCHOTHERAPY
language, even when therapists and clients agree about terminal values
in therapy, they may disagree about instrumental values.
Psychotherapy ought to be based on science, not values
Others who challenge the idea that therapy is value-laden argue that the
idea represents a fundamental misunderstanding of the nature of therapy.
Therapy is a scientific rather than an ethical endeavor, stemming solely
from scientific findings about diagnosis, etiology, empirically validated
behavioral interventions, efficacious treatments, and the like.
I believe that psychotherapy is, or at least ought to be, based in part on
scientific findings. For example, attempts to discover empirically the
relationship among the (self-reported) values of therapists and clients and
therapeutic outcome—as in the sustained research program of Beutler
and colleagues (e.g. 1970, 1981; Consoli and Beutler 1996)—are legitimate
and essential. To the extent we thereby discover the values, or therapist—
client value matches, that produce optimal client improvement,
therapists should alter what they do accordingly.
But even if science produces unequivocal empirical findings that would
permit definitive prescriptions for therapist behavior regarding values
and other therapeutic techniques (and so far it has not), other questions
remain: which outcome measure should we employ in measuring
“optimal client improvement”? which definition of mental health should
we adopt? To reiterate points just made, full agreement about the
meaning of mental health (outcome), especially when viewed broadly as
ideal human functioning, does not exist. And all therapy goals rest on
values. Accordingly, in and of itself, empirical research cannot
definitively or exhaustively address the ethical questions of ideal therapy
goals or the proper means by which therapy is carried out. Attempts to
“solve” the problem of values in therapy on an entirely scientific basis
may thus rest on a value-laden definition of mental health. Such attempts
will likely contribute to our understanding of the problem, but not,
finally, solve it.
This by no means entails a rejection of science, however. One can hold
that empirical findings are very helpful, indeed, essential, without also
accepting the philosophical claim that science alone can produce
knowledge about ethics, values, and the ethical dimensions of therapy. I
can summarize my dialectical position in two theses:
Science alone will not resolve the ethical questions raised by the presence of
values in therapy.
The ethical questions raised by the presence of values in therapy cannot
be adequately resolved without relying upon pertinent scientific findings.
I thus reject the notion that we must choose either science or ethics to
address values in therapy. That notion, and the related differentiation
INTRODUCTION 9
between philosophy and science, bears close scrutiny, in part because, as
Koch noted, “psychology is necessarily the most philosophy-sensitive in
the entire gamut of disciplines that claim empirical status” (Koch 1981:
267). And Leahey observed that “psychology, more than any other
science, occupies treacherous middle ground between is and ought”
(Leahey 1992: 470).
My claim is that we need to move beyond arguments about whether
questions of values in therapy are to be solved by scientific or by
philosophical means, and focus on how to draw upon both scientific and
philosophical questions to understand the ethical dimensions of therapy.
Accordingly, I believe that the ethical questions raised by the presence of
values in therapy cannot be adequately resolved without relying upon
pertinent scientific findings. And that progress in understanding values and
ethics in therapy requires in-depth philosophical reflection.
Sorting out the respective contributions of scientific methods and
philosophical reflection is, to be sure, knotty and controversial. But I am
convinced that psychologists’ profound resistance to philosophical
reflection (in Chapter 6, some of the historical reasons for this resistance
will be explored) has contributed substantially to the failure of mental
health professionals to develop a more intellectually satisfying
understanding of ethics and values in psychotherapy.
It is meaningless to claim that values or ethical
assertions in psychotherapy can be true or correct
Logical positivists and others raise an additional challenge to the claim
that therapy is value-laden, indeed, to any discussion of the ethical
character of therapy. One version of this type of position, which I will call
the positivist ethical theory, makes assertions like the following:
Since there can be no truth-value attributed to ethical statements, it
is cognitively meaningless to claim to understand values in therapy,
or to discuss which values ought to be present. For instance, it is
meaningless to argue that it is good for a client to move in a healthier
direction. We can only say we prefer the client to do so. The values
of the mental health professional about therapy goals thus carry no
more epistemic weight than those of a garbage man, physicist, or
cult leader. Not even experience or science permits us to draw
conclusions about the goodness of therapy goals or about which
values ought to be present in psychotherapy.
Other ethical positivists would concur that it is pointless to discuss which
values ought to be in therapy. But they would nonetheless argue that the
empirical investigation of “values” (where “values” is a descriptive term
referring to beliefs or feelings about matters commonly considered to be
10 ETHICS AND VALUES IN PSYCHOTHERAPY
“ethical”) is a meaningful activity, indeed, that it is an essential task, one
for which the scientific method is well suited. This disagreement likely
stems, in part, from the issue to which Chapter 5 is devoted—the
multiple definitions of “values.” If both types of positivists agree that
“values” is a strictly ethical term (so values have to do with goodness,
rightness, obligation, virtue, and the like, and thus can be correct or
incorrect), then both would likely agree that a claim to explain “values” is
meaningless—because “values” cannot be investigated empirically.
However, if one party assumes everyone uses values in a strictly ethical
sense, but the second party assumes everyone employs it as a descriptive
term, communication will be impaired.
(This illustrates a major reason for the impasse reached by those
striving to understand and address values in therapy: the profound
ambiguity of the term “values.” From this follows a thesis that will be
addressed in Chapter 5: definitional disparities and conceptual confusion
regarding the term “values” have greatly impeded progress in understanding
and addressing values in therapy and the ethical dimensions of therapy.)
However, positivists who assume it is meaningful to study values
empirically and positivists who assume it is not both concur in believing
that it is meaningless to make assertions about goodness or obligation.
Based on that philosophical position, they claim that it is cognitively
meaningless to ask what values ought to be pursued in therapy. Their
claim raises further questions: on what philosophical grounds do its
adherents support it? how do therapists adopting this philosophical
position address the logical and other objections to the positivist theory
of ethics, objections that have led almost all philosophers to reject it? how
do such psychotherapists work with clients whose cultural, subcultural,
religious, or personal philosophical beliefs are at variance with that
ethical theory?
In summary, the positivist ethical stance does not mean that
philosophical positions regarding values in therapy are avoided in favor
of science, but rather that a particular philosophical position is adopted,
often implicitly and sometimes in a way that is hidden from clients.
Others committed to science support alternative ethical theories, arguing
that a commitment to science does not require a therapist to become an
ethical positivist.
Psychotherapy is not value-free. So what?
The final response to the claim that therapy is value-laden is perhaps not
aptly described as a challenge to the claim. Rather, the response is one of
boredom:
Yes, of course therapy is value-laden. The solution to “the problem”
is very straightforward: Therapists need to be aware of their own
INTRODUCTION 11
values and not impose them on clients. So these issues are not,
finally, difficult at all. Or very interesting.
Or, “Yes, I know therapy is value-laden. So what?”
This position deserves consideration; superficial analyses, which have
abounded in this arena, warrant such ennui. Flawed analyses of ethics,
values, and therapy will result in the conclusion that the issues are boring
and the answers simple. I am convinced, however, that those who
examine these issues carefully will be struck, not with the simplicity of
the issues, but with their extraordinary complexity, and with the barren
superficiality of “simple” explanations of them. As H.L.Mencken noted,
“For every complex problem there is a simple answer. And it is wrong”
(cited in Smith and Anderson 1989:1154).
Some psychotherapists would agree that the issues are complex, but
nonetheless assert that the solution is simple. Because of what they see as
the opacity of the problems (rather than their simplicity) and because
they argue it is pointless to ask questions like “with which values ought
therapy to be laden?”, these psychotherapists propose a simple, practical
solution: therapists need to be aware of their values and not impose them
on clients.
Both the view that the problem is simple and the view that the issues
are hopelessly complex may thus lead to the same conclusion: the
solution is simple. Contrariwise, I will argue that making progress is
extraordinarily difficult, in part because therapist awareness of their own
values is neither a simple nor a sufficient solution. For example, it is
likely that therapists sometimes influence the values of clients and of
society, whether or not they are aware of their values or intending to
change the values of others, and even if they are not “imposing” values
on others. This raises ethical problems, which I can articulate in the form
of a thesis:
The conversion of a client’s values and ethical theory to those of his or her
therapist is, prima facie, unethical.
Because we do influence the values of others, I will argue, we have a
professional responsibility to reflect with great care on the values and
ethical theories we hold, lest our value influence be less than optimal.
Accordingly, more sophisticated analyses of values and ethics in
therapy need to be developed, both to understand adequately the ethical
dimensions of therapy and to permit practice consistent with the highest
possible professional standards.
Developing more sophisticated analyses does require awareness of
one’s own values (the “half-truth” in the “simple” solution). But it is also
vitally important that psychotherapists critically examine values and
ethical theory, their own and those of others, and especially those held by
clients. This means thinking about alternative analyses of values and
ethics (including the best ethical answers from across the centuries and
12 ETHICS AND VALUES IN PSYCHOTHERAPY
from other cultures), exposing one’s own beliefs to rational scrutiny, and
entering into dialogue with those holding other views. It also requires a
careful “unpacking” of the various uses of “values.” Scientific (including
biological, psychological, sociological, and anthropological), cultural,
religious, philosophical, and literary perspectives on values and ethical
theory may add depth to our understanding of values and ethics in
general, of our own values and ethical positions, and of the values and
ethical positions of clients. These tasks are multi-faceted and intricate,
requiring us to explore philosophically-laden waters many experience as
deep and murky.
Some will no doubt be bored by such an exploration. Some will no
doubt continue to assert that such explorations are pointless, and the only
solutions simple. This book is written for people open to the possibility
that progress in understanding and addressing values and ethics in
therapy can occur, albeit progress which is likely to produce answers that
are neither simple nor definitive.
In conclusion, when the various challenges to the idea that therapy is
value-laden are examined closely, it becomes evident that we need more
sophisticated analyses of the ethical character of psychotherapy. Because
when a therapist moves into a realm beyond what is consensually agreed
to be therapeutic, when a therapist operates out of a school of therapy
associated with particular values, when a therapist selects a goal for
therapy (however consensual), when a therapist concurs with a goal a
client selects, when a therapist adopts a position about the relationship of
science and ethics, when a therapist adopts a position about the
meaningfulness and/or truth of an ethical position, when a therapist
concludes that understanding and addressing values in therapy is a
simple matter, and when a therapist makes a response to a sad client who
wants to know what he or she should do, that therapist is engaging in a
value-laden activity, that therapist is functioning as an ethicist.
Therapists need to palpate the ethical structure of psychotherapy more
sensitively, to understand the various dimensions of values in
therapeutic relationships more adequately. Accordingly, it is to a
constructive exploration of values and ethics that this book is devoted,
“constructive” because I think we can make progress in understanding
and addressing values and ethics, and “exploration” because we must
enter complex, murky waters with no promise that we will obtain certain
answers. It is to an overview of the ways in which I will proceed with this
exploration that I now turn.
Ethics, “values,” and psychotherapy intertwined: an
overview
To maximize progress in understanding and addressing values and
ethics in therapy, I am convinced that we need to combine traditional
scientific and nontraditional approaches. In the discussion to follow, I
will thus rely more heavily on scientific findings and methods than
INTRODUCTION 13
philosophers customarily do. I will also address issues, such as
philosophical and religious issues, that are foreign to many
psychotherapists. And I will use methods, including those that are
philosophical, cultural, and historical, that are unfamiliar to many
psychotherapists. I use that full range of methods because I am convinced
that an in-depth understanding of the thorny issues of values and ethics
in therapy requires doing so.
Because of the many complexities entailed in addressing ethics and
values, because key terms like “ethics” and “values” are used in divergent
ways, and because of the philosophical nature of many of the issues
involved, the first section of the book will be devoted to in-depth
clarification of several key concepts. In Chapters 2 and 3, I will will address
the multiple meanings of “ethics” and “ethicist,” clarifying what I mean
by those terms and by my claim that therapists function as ethicists. In
addition to clarifying my meanings of these terms, I will also argue that
psychotherapists need to draw upon the traditions and analytic
approaches of philosophical ethics and to develop increased ethical
sophistication.
In Chapter 4, I will discuss ethical theory, a summary term for a wide
range of theoretical issues pertaining to the intellectual foundations of, or
justificatory discourse regarding, specific values, codes of professional
ethics, and a variety of other ethical dimensions of the practice, theory,
research, institutions, and discourse of psychotherapy. In that chapter, I
will tackle issues such as the meaningfulness of making assertions like
“Therapists ought not have sexual relations with their clients,” how one
arrives (if at all) at ethical knowledge, ethical principles, the basis of
moral obligation, and the relationship of religion to values and ethical
theory. That therapists need to consider these issues (especially religion)
is, of course, controversial. I will argue, however, that examining these
intellectual dimensions of ethics and values in therapy provides an
essential perspective on the ethical character of therapy. For instance,
even though many (and perhaps most) therapists are not religious, some
of their clients are likely to be. Because ethics and values are inextricably
tied to religion for some clients (though obviously not for all), fidelity to
clinical reality, and any comprehensive explanation of values in therapy,
must thus touch upon religion. To sharpen the terms of the debate, I argue
that:
Since some therapists and many clients base their values, and their ethical
theory, in some substantial measure on their religious convictions, no
account of ethics and values in therapy that claims to be adequate and
comprehensive can ignore religion.
Due attention will, of course, be paid to empirical research regarding
religious demographics and correlates of religiousness.
14 ETHICS AND VALUES IN PSYCHOTHERAPY
The discussion of ethical theory in Chapter 4 will make more fruitful
the discussion of the meanings of “values” in Chapter 5. When the
significant differences between various definitions are clear (involving
deep-seated differences in ethical theory and underlying metaphysical
and epistemological assumptions), the psychological and philosophical
literature on values and ethical theory will make much more sense.
Chapters 6 and 7 will be devoted to a discussion of some of
psychotherapy’s key historical, intellectual, and social contexts.
Therapists have long known the importance of their clients’ familial,
social, cultural, and other contexts, and have become increasingly
sophisticated in assessing those contexts. In these chapters, I will look at
some contexts relevant to an understanding of therapy’s values and
ethical dimensions. I will focus on the intellectual and social contexts out
of which contemporary psychotherapy grew, considering how these
contexts both shape and obscure therapy’s ethical dimensions. I will
focus on how the ethical, scientific, clinical, and business contexts of
psychotherapy relate to ethics and values in therapy. This will permit a
more rigorous and comprehensive intellectual evaluation of the ethical
dimensions of therapy.
With the conceptual tools discussed in Chapters 2 through 5 and an
understanding of some of the historical, intellectual, and social contexts
of psychotherapy (discussed in Chapters 6 and 7) at our disposal, we can
turn to a more focused discussion of psychotherapy, addressing what
happens when a sad client asks a therapist, “What should I do?” The
ethical dimensions, or value-ladenness, of therapy process and outcome
will be discussed in Chapters 8 and 9, respectively. I will examine the
ethical dimensions of psychotherapeutic techniques and processes, and
the values contained (usually implicitly) in therapy goals and evaluations
of outcome. Both descriptive and evaluative dimensions of process and
outcome will be addressed, with some key concepts from the empirical
research literature analyzed in terms of the ethical considerations
discussed in the first six chapters.
In the last section of the book, I will draw some implications that follow
from thinking about therapy as value-laden and the therapist as ethicist. I
will do so under three headings: the need for a more adequate public
philosophy about the optimal role of psychotherapy in society; rethinking
professional ethics; and the challenge facing therapists who want to
perform well a task to which their craft commits them (but for which they
are rarely well-trained), the task of being an ethicist, of addressing well
the ethical character of psychotherapy.
I will address the issue of a public philosophy for psychotherapy in
Chapter 10 for two reasons: ideas and agreements within a society about
psychotherapy represent another ethical dimension of psychotherapy
which warrants examination; and current societal ideas about therapy
still tend to assume that therapy is value-free. Since it is not, but the
existing societal contract about therapy assumes it is, the role of therapy
in society and the societal contract about therapy need rethinking, a task
INTRODUCTION 15
that is particularly challenging in societies in which there is little ethical
agreement.
Given therapy’s value-ladenness, professional ethics also needs to be
reconsidered, especially since the working assumptions of many mental
health professionals (and perhaps some of the framers of professional
codes of ethics) still reflect a belief in value-free therapy, a positivist
ethical theory, or both. The central issue is this: in light of the pervasively
ethical character of psychotherapy and the wide diversity of
contemporary ethical convictions, how do therapists responsibly function
as ethicists?
I will conclude in Chapter 12 with a discussion of how therapists and
other therapy stakeholders can address most effectively the full range of
ethical questions to which therapy is tied and make better choices about
the ethical character of psychotherapy. That is, I will discuss how therapy
stakeholders, including therapists, can best function as ethicists.
I should add that, by focusing on how therapists function as ethicists, I
do not intend to claim that the psychotherapist is only an ethicist, always
an ethicist, or primarily an ethicist. Psychotherapy is also an economic
activity. So we can analyze it in the terms of the discipline of economics.
But it does not follow that therapy can be reduced to strictly economic
terms. Or that it ought to be. The ethical dimension of therapy is but one
of many dimensions of therapy, albeit one of its often unspoken,
unacknowledged, and understated sides. If, however, the ethical
dimensions of therapy and the role of the psychotherapist as ethicist
ought not be exaggerated, neither ought they be denied or ignored.
I am convinced that an acknowledgment that therapists function as
ethicists does not, and ought not to, sanction therapist dogmatism or
therapeutic moralism. I believe a mature approach to values, ethics, and
therapy will be humble and tentative. I agree with Caplan who, when
considering whether it might jeopardize modesty to assert that ethical
expertise exists, asserted, “it is those who lay claim to the mantle of
expertise who best understand how little is known or understood with
certainty about morality” (Caplan 1989:83). The challenge thus facing
therapists is this: while avoiding despair and dogmatism, what better
answers about ethics, values, and therapy can we discover?
To begin answering that question, to start clarifying the ways in which
psychotherapists are, for good and ill, ethicists, I will first examine the
meanings of “ethics” and “ethicist.”
2
Ethics
Challenging, inescapable questions
The phrase “psychotherapist as ethicist” has a decidedly odd ring. While
generally considered to be ethical, psychotherapists are not customarily
considered to be ethicists. What does it mean to claim that therapists are
ethicists?
In large measure, this book is devoted to an exploration of that
question. But clarity requires a preliminary discussion of the many
meanings of “ethics” and “ethicist.” Because ethicists address issues
pertaining to ethics, I will first address ethics.
Dimensions of ethics
Ethics has to do with a wide range of questions about what is good, right,
and/or virtuous and with questions of value (in some uses of “value”). As
Slote noted, “Over the millennia, thoughtful people and philosophers
have asked what kind of life is best for the individual and how one ought
to behave in regard to other individuals and society as a whole” (Slote
1995: 721). These perennial ethical questions, although perhaps not fully
answerable, cannot be avoided entirely. To address them, we need to
examine six distinguishable but intertwined dimensions of ethics:
professional ethics, theoretical ethics (i.e. philosophical ethics or moral
philosophy), clinical ethics, virtue ethics, social ethics (including
regulatory and policy ethics), and cultural ethics. All pertain to
psychotherapy.
To ground the discussion in this and the following chapter, consider
this case:
Mike, a 37-year-old depressed computer programmer, enters
therapy. In the third session, his therapist learns that Mike has been
having a series of affairs, about which he has some guilt, balanced
against his feeling that having the affairs is his right as a male because
his wife occasionally declines his sexual advances. His wife is
unaware of these affairs, and he lies to prevent her from learning of
them. Mike has met several of his paramours through his extensive
ETHICS 17
involvement with a progressive community organization that
challenges injustices faced by the poor in the community’s
impoverished, largely minority, inner-city neighborhoods. Intrigued
by his line of reasoning justifying extra-marital involvements and
by the labyrinthine logistics required to sustain multiple
surreptitious affairs, Mike’s therapist (whose own marriage is none
too fulfilling) mentions the case to his buddies on the golf course.
Seeing their fervent interest, he entertains them with numerous
illustrative anecdotes, which permits one of the golfers to identify
the client as one of his employees. Mike is terminated from therapy
when he reaches the six-session psychotherapy limit set by his
Health Maintenance Organization (HMO). Although the therapist
failed to pick up on his alcohol abuse, Mike leaves therapy feeling
much less depressed (“You’re right. I get depressed whenever I say
‘should’ to myself. 111 just stop doing that.”).
Professional ethics
Several professional ethical issues are readily apparent: the therapist’s
violation of confidentiality, the influence of the therapist’s apparently
unresolved marital issues on his handling of the case, and (possibly) the
therapist’s failure to screen for alcohol abuse and to request additional
sessions from the client’s HMO.1 One way to conduct an ethical analysis
of psychotherapy is to employ codes of professional ethics: therapists’
behaviors would be examined in terms of their profession’s ethical
standards.
Codes of professional ethics (e.g. American Association for Marriage
and Family Therapy 1991; American Psychiatric Association 1993;
American Psychological Association 1992; National Association of Social
Workers 1993) set the standards that govern members of the profession in
their interactions with clients. As Haas and Malouf note, professionals
“take on special duties to persons who enter professional relationships
with them” (Haas and Malouf 1995:2). Those who enter a profession
agree to abide by the standards set forth in the profession’s code of ethics
(Ozar 1995). Such codes, and the ethical assertions they make, are
ancient. The Hippocratic Oath, for instance, dates back at least 1900
years, with literature articulating the ethics of Greek doctors appearing as
early as the fifth century BC. “The popular ideal of the physician,”
Amundsen notes, “was a dedicated, unselfish, and compassionate
preserver or restorer of health—and, sometimes, inflicter of health-giving
pain—always committed to the good of the patient” (Amundsen 1995:
1510).
That classic exemplar of professional ethics—medical ethics—has been
thoroughly scrutinized in recent years. In response to the plethora of new
ethical issues produced by an explosion of medical advances, some
18 ETHICS AND VALUES IN PSYCHOTHERAPY
serious problems with medical ethics in particular, and with professional
ethics in general, have been identified by physicians, moral philosophers,
theologians, and others (Veatch 1989b). And they have also established
the extensive, rapidly growing, multi-disciplinary field of bioethics,
which incorporates medical ethics but is much broader, including all of
the life sciences, philosophy, law, theology, and the social sciences
(Callahan 1995; Reich 1995b). Callahan suggests that bioethics consists of
four distinguishable “general areas of inquiry…[which] can be
distinguished even though in practice they often overlap and cannot
clearly be separated” (Callahan 1995:250).
Because considering those four dimensions of ethics, in conjunction
with professional ethics, permits a richer ethical analysis of
psychotherapy, because doing so permits us to address the challenges
posed to professional ethics in general (Veatch 1989b), and because I
think we can learn by exploring the analogy between the ethical issues
faced by the physician and the ethical issues faced by the psychotherapist
(obviously so for the psychiatrist), I will extend to psychotherapy a
modified version of Callahan’s (1995) four-fold consideration of ethics. I
will consider in turn professional ethics, philosophical ethics, clinical
ethics, virtue ethics, social ethics, and cultural ethics.
But before I do so, I want to point out several areas of discontinuity
between professional ethics (narrowly construed2) and the broader
ethical issues raised in philosophical ethics, clinical ethics, virtue ethics,
social ethics, and cultural ethics.
Codes of professional ethics are generated, in the first instance, from
within the profession rather than from the kind of multi-disciplinary
effort common in bioethics. Although those writing about professional
ethics sometimes draw upon the thinking of philosophers and others
(e.g. K.S. Kitchener 1984, 1986), the primary responsibility for developing
professional codes of ethics rests within the profession itself. This has
been challenged in two ways: Veatch (1989b) and others have argued that
clients (the purported “partners” in the psychotherapeutic endeavor) and
other key stakeholders should participate in the development of
professional ethical standards. And governmental agencies have
mandated changes in professional codes of ethics, for example when the
US Federal Trade Commission required changes, first in the American
Medical Association’s code of ethics, then in the ethical code of the
American Psychological Association (APA) (modifying the prohibition
against some forms of advertising and referral fees, APA 1992; Bersoff
1995; Canter et al. 1994: Koocher 1994).
Second, professional ethics is narrower in scope than other dimensions
of ethics. Professional ethics applies only to the members of a particular
discipline and only to the role-specific functions of the professional
(Bassford 1990). Professional ethics is also code-focused. Such codes,
occasionally revised, outline the professional’s obligations and, in some
instances (e.g. APA 1992), outline ideal behaviors to which a therapist is
to aspire (Canter et al. 1994). In addition, codes of professional ethics do
ETHICS 19
not pertain to the ethical analysis of clients (e.g. whether it is good for
Mike to combat injustice or wrong to lie to his wife).
Finally, codes of professional ethics do not generally contain a rationale
for the principles and standards they contain. Psychologists, for instance,
are told that “Psychologists do not engage in sexual intimacies with
current patients or clients” (APA 1992:1605), but the reasons for that
prohibition are not included in the code.
Accordingly, although a full-fledged analysis of the ethical dimensions
of psychotherapy must include codes of professional ethics, stopping
with them would mean ignoring many important questions. An analysis
of the therapy Mike received that relied solely upon professional codes of
ethics would not address the following issues:
ethics in general: Mike’s own standards of right and wrong (injustice is
wrong; infidelity is okay when one’s wife doesn’t “put out”).
theoretical ethics: the intellectual grounding for mandating, for instance,
that Mike’s therapist maintain client confidentiality (the reasons for that
ethical standard).
clinical ethics: the practical clinical challenge of
(a) optimally reducing Mike’s depression (that is, in the best possible, or
“most good,” way) and
(b) working in partnership with Mike so he changes in the best possible
(“most good”) direction
within six sessions, doing so in the context of: Mike’s lying to his
wife; possible physical harm to Mike, his wife, and his other sexual
partners stemming from the uncertain HIV status of Mike and the
women with whom he is sexually involved; Mike’s (sexist)
assumption that it is his right to have affairs if his wife declines his
sexual advances; and his assumption that the key to eliminating
depression in his life is to eliminate his use of “should” (which
could be understood as eliminating from his life any binding moral
obligations).
virtue ethics: enduring, trans-situational moral and nonmoral ethical
characteristics of therapists, clients, and other therapy stakeholders (e.g.
integrity, honesty, warmth, and empathy).
social ethics:
• the impact on society if all psychotherapy clients eliminate all
“shoulds” from their lives in order to achieve individual well-being
• ethical issues, such as harm to individuals and the general welfare,
stemming from HMOs terminating clients after six sessions (regulatory
and policy aspects of social ethics).
20 ETHICS AND VALUES IN PSYCHOTHERAPY
cultural ethics: the influence of culture on the ethical beliefs of:
Mike
his therapist
the present reader of this book, and
the author of this book
To address these and other ethical issues, we need to move beyond
professional ethics and draw upon the five other overlapping dimensions
of ethical reflection.
Theoretical ethics
Psychotherapists and others engaged in theoretical ethics address the
intellectual foundations of ethics. To refer to such philosophical or
theoretical reflection, Pojman offers the following definition of moral
philosophy:
the systematic endeavor to understand moral concepts and to justify
moral principles and theories. It undertakes to analyze such
concepts as “right,” “wrong,” “permissible,” “ought,” “good,” and
“evil” in their moral contexts. Moral philosophy seeks to establish
principles of right behavior that may serve as action guides for
individuals and groups. It investigates which values and virtues are
paramount to the worthwhile life or society. It builds and
scrutinizes arguments in ethical theories and seeks to discover value
principles (e.g. “Never kill innocent human beings”) and the
relationship between those principles (e.g. does saving a life in
some situations constitute a valid reason for breaking a promise?).
(Pojman 1995b: 2–3)
Although theoretical ethics (or ethical theory or moral philosophy) can
address the foundations of professional ethics (e.g. Blackstone 1975;
Camenisch 1983; Freedman 1978; Goldman 1980), it applies as well to the
full range of ethical issues. A flavor of the type and range of such
theoretical ethical issues can be seen in the following examples:
If Mike is well-advised to eliminate “shoulds” from his life, why?
What justification can be given for Mike’s belief that society
ought to treat minorities justly?
On what grounds could a therapist claim that “All moral
assertions are relative to individuals or cultures, so no universal
moral claims can be made”?
ETHICS 21
What reasons justify the psychotherapeutic professions’ claim
that “Ethical psychotherapists should normally uphold client
confidentiality”?
Although a more complete discussion of such theoretical issues will be
provided in Chapter 4, one debate within theoretical ethics warrants
consideration here, because it bears on the discussion in Chapter 3 about
who can be considered an ethicist. The issue in dispute is the disciplinary
home for the grounding for ethics. Bioethicists debate whether the
foundations of bioethics “should be looked for within the practices and
traditions of the life sciences, or whether they have philosophical or
theological starting points” (Callahan 1995:250). With regard to
psychotherapy, the question is whether the basis for professional and
other ethical issues should be founded within philosophy or within the
disciplinary homes of psychotherapists, that is, within psychology,
medicine, social work, and so forth.
The traditional origin myth of American psychology’s code of ethics
clearly places its genesis within psychology; psychologists used empirical
methods with other psychologists to formulate it. That is, the basis of the
original code was a survey conducted to discover psychologists’ opinions
about situations believed to be ethical in nature, about behaviors in which
psychologists should and should not engage, and about principles
psychologists should uphold. And Nagy asserts that in updating the 1992
APA code, “an empirical basis…was the foundation of the code” (Nagy
1994:505). Such traditional accounts have failed, however, to explain why
the opinions of the psychologists from whom the code has been derived
should be given any special epistemic weight.
Others argue that, in addressing questions of theoretical ethics,
psychotherapists should rely upon professional philosophers to provide
the intellectual justification for the ethical issues involved in
psychotherapy. And, indeed, ethics, as a branch of philosophy (e.g.
Pojman 1995a, 1995b), is devoted precisely to such theoretical issues.
To address this contentious issue, bioethicists have begun to rely upon
both medicine/biology and the more traditional ethical disciplines. As
Callahan notes, “with time these two sources become mixed, and it seems
clear that both can make valuable contributions.” Accordingly, in
bioethics, physicians learn from philosophers and theologians. And
philosophers and theologians “draw strongly upon the history and
practices of the life sciences to grasp the aims and developments of these
fields” (Callahan 1995:251, 250). If psychotherapists want to draw upon
the experiences of bioethicists, we need to develop a theoretical ethics
pertaining to psychotherapy that possesses a deep appreciation for
theoretical ethics and the aims and nature of psychotherapy (that is, an
ethics that grows, in some sense, out of the practices and theories of
psychotherapy). Accordingly, it may be optimal for philosophers,
22 ETHICS AND VALUES IN PSYCHOTHERAPY
psychotherapists, and others to collaborate in constructing an adequate
theoretical ethics for psychotherapy.
Clinical ethics
In contrast to theoretical ethics, clinical ethics have to do with the
practical ethical decisions a clinician makes, “with the ethics of clinical
practice and with ethical problems that arise in the care of patients”
(Fletcher and Brody 1995:399). According to Callahan, clinical ethics
“typically focuses on the individual case, seeking to determine what is to
be done here and now with a patient” (Callahan 1995:250). As such,
clinical ethics is one form of applied ethics, which is often contrasted with
theoretical ethics (Pojman 1995b; Veatch 1989a). However, as we shall see,
it is problematic to distinguish too sharply between applied and
theoretical ethics.
Psychotherapists face two broad classes of clinical ethical issues: those
related to the processes of therapy and those related to the goals of
therapy (these issues will be addressed more systematically in Chapters
8 and 9 respectively). A clinical ethical analysis of Mike’s psychotherapy
would include questions like the following:
How should Mike’s therapist interact with him?
What therapist qualities ideally characterize the therapeutic
relationship?
How should a therapist
• treat Mike’s depression?
• handle Mike’s lying to his wife?
• address Mike’s failure to be tested for HIV or to request that his
sexual partners be tested?
Would it have been better (more good) for Mike’s therapist to have
evaluated his substance abuse?
What goals should be established (would be best, or “most
good”) for Mike’s therapy?
What kind of person should Mike become (e.g. mentally healthy,
self-aware, more honest, etc.)?
How does a clinician address possible conflicts in goals?
• the conflict between Mike’s goal of reduced depression and a
therapist’s goal of Mike developing healthier intimate
relationships—characterized by Mike Mike’s monogamy, his
honesty with his wife, or both?
ETHICS 23
• the conflict between the goal shared by Mike and his therapist—
minimizing Mike’s depression—and a third-party payer’s goal—
minimizing costs?
Should a therapist always defer to a client’s stated goals for therapy
or defer to a third-party payer’s goals? If not, under which
circumstances should a therapist not accept a client’s or third-party
payer’s goals?
What responsibility, if any, does a therapist have to weigh the
beneficial effects for the client of minimizing the client’s ethical
sensitivities (no more “shoulds”) against the effect of such an action
on society? That is, is it the therapist’s responsibility to weigh
individual-client mental health (one form of good) against societal
well-being (another form of good)? If not, whose responsibility (if
anyone’s) is it?
In addressing such questions, applied ethicists distinguish between
“principles-oriented” or “top-down” approaches to ethical decisionmaking and “case-oriented” or “bottom-up” approaches (Callahan 1995;
Fraser 1989). In the former approach, principles derived from
philosophical analysis (e.g. autonomy and beneficence) are applied to
concrete cases to provide answers to clinical ethical issues. One could
argue, for instance, that a proper application of the principle of promisekeeping would have led Mike’s therapist to refrain from violating Mike’s
confidentiality on the golf course.
By way of contrast, clinicians employing bottom-up approaches would
immerse themselves in the particularities of Mike’s case. They would find
the brief rendering of the case given here superficial and inadequate,
lacking essential nuance, detail, context, narrative, and history. The
context of a clinical ethical decision is considered critical (Jonsen et al.
1992).
One example of a bottom-up approach is a new form of casuistry, a
“method of analyzing and resolving instances of moral perplexity by
interpreting general moral rules in light of particular circumstances”
(Jonsen 1995:344). Advocates do not reject ethical principles, but
thoughtfully consider the appropriateness of those principles in a given
clinical instance. As Jonsen puts it, “principles are seen to be relevant to
cases in varying degrees: In some cases, principles will rule
unequivocally; in others, exceptions and qualifiers will be appropriate”
(ibid.: 349).
A second type of bottom-up approach, proposed by feminist ethicists,
also stresses the importance of context (e.g. Sherwin 1992). In contrast to
the rationalistic, top-down approaches sometimes considered
characteristically male, feminist ethicists place “a far heavier emphasis on
the context of moral decisions, on the human relationships of those caught
24 ETHICS AND VALUES IN PSYCHOTHERAPY
in the web of moral problems, and on the importance of feeling and
emotion in the making of moral decisions” (Callahan 1995:253).
It may be inappropriate to draw too stark a distinction between caseand principle-oriented approaches. Edel points out that “the great moral
philosophers…explicitly connected their theory to…practical problems of
their time” (Edel 1986:317). And so their approaches involved both
principles and cases, and employed both top-down and bottom-up
thinking. And Callahan (1995), Veatch (1989a), Clouser (1989), and others
remind us that no sharp distinction can be drawn between ethical theory
(or theoretical ethics) and applied or clinical ethics. One dialectical
alternative is known as “wide reflective inquiry” (Brody 1989; Callahan
1995; Daniels 1979; Rawls 1980). According to Callahan, this approach
“espouses a constant movement back and forth between principles and
human experience, letting each correct and tutor the other” (Callahan
1995:252). Such an approach is very similar to how many therapists
approach theories of psychotherapy: their theories are influenced by their
clinical practice, and their clinical practice by their theories, with both
practice and theory being revised continually by exposure to one
another.
Virtue ethics
Psychotherapists and others who employ virtue ethics stress the stable
ethical characteristics of persons rather than the ethical principles people
employ, the way they resolve ethical dilemmas, or the behaviors they
exhibit. For example, Doherty (1995) argued that therapists should be
caring, a virtue Mike lacked but which Doherty, feminists (e.g. Noddings
1984), and others have emphasized. And Mike’s therapist failed to exhibit
what Dyer called the “central virtues of the medical profession” (Dyer
1988: 108): trustworthiness and respect for confidentiality.
Meara, Schmidt, and Day addressed the relevance of virtue ethics for
psychologists and other therapists. They provided this definition: “The
concept of a virtue or trait of character denotes a quality or qualities of a
person that have merit or worth in some context, and these qualities are
often related to matters of right conduct (i.e. morality)” (Meara et al. 1996:
24).3 They think virtue ethics complement more traditional principle
ethics and need to be integrated with them. They also assert, however,
that virtue ethics make a distinctive and important contribution to ethics.
Several features of an approach to ethics that emphasizes virtue can be
identified. The person is the focus of attention, not abstract rules, type of
ethical reasoning, response to ethical dilemmas, or moral behaviors. We
need to ask “Who shall I be?” not “What shall I do?” (Jordan and Meara
1990: 107). Virtue ethics provide a pervasively psychological approach to
ethics. And so Drane held that character, a term related to virtue, refers to
“personality structure, with special emphasis on its ethical components”
(Drane 1994:291). “Virtue” incorporates the behaviors, ways of thinking,
judgments, perception of ethically relevant features of situations,
ETHICS 25
relationships, emotions, and motivation of people (Punzo 1996; Meara et
al. 1996). Virtue ethics is also more wide-ranging and inclusive than
approaches employing principles alone. As Brody put it, virtue ethics is
“a broader perspective that embraces the whole of a life and not simply
the one decision that is at hand” (Brody 1994:211). Finally, many virtue
ethicists emphasize the role of a community in shaping virtues
(MacIntyre 1984; Meara et al. 1996). Others who emphasize virtues are,
however, more self-focused, concerned about the desirable characteristics
of individual persons and give little attention to community (see
Meilaender 1984).
From the perspective of virtue ethics, therapists can, and perhaps
should, exhibit particular virtues. Meara et al. (1996), for instance,
suggested that therapists should exhibit prudence, integrity,
respectfulness, and benevolence. And, as we shall see in Chapter 9,
therapists may establish goals for clients, like “becoming mentally
healthy”, that are perhaps best understood as virtues. And virtues can be
used as criteria for evaluating therapy outcomes.
Social ethics
In contrast to the clinical ethicist’s focus on the micro-picture of the
clinical encounter and the self-focused virtue ethicist’s focus on the
character of the individual person, those who pursue questions of social
ethics focus on macro issues. Social ethics can be defined as “the
normative study of communal conduct” (Facione et al. 1991:9, emphasis
added), in contrast to personal ethics, which is concerned with value
judgments about individual conduct.
Accordingly, social ethics has to do with the ethical dimensions of
personal partnerships (e.g. marriage), families (variously defined), various
social structures, communities, and society as a whole. Among the issues
addressed are justice (especially distributive justice), the proper
relationship between individuals and larger social entities, social policies,
the “good society,” and the general welfare. When addressing
psychotherapy, social ethics can involve ethical analyses of society’s
impact on psychotherapy and of psychotherapy’s impact on society.
That social ethics is not foreign to psychology may be seen in the
statements of purpose of groups such as the American Psychological
Association (APA) and the American Psychological Society (APS). They
exist, in part, for the purpose of “promoting human welfare” (APA 1994:
1) and “the improvement of human welfare” (APS 1988:1). And ethical
analyses of psychotherapy that address its social impact (e.g. Rieff 1959)
now have a long history.
Although philosophers do not always distinguish social ethics from
ethics in general, I think it important to do so here for several reasons: to
highlight the ethical aspects of regulatory and policy decisions (especially
those made which are playing an increasingly large role in the lives of
psychotherapists; to address the relationship between society and both
26 ETHICS AND VALUES IN PSYCHOTHERAPY
professionalism and professional ethics; to counteract a common image
of ethics as the solitary individual wrestling with a very personal ethical
decision; and to highlight the social ethical dimensions of psychotherapy
at a time in history when many think it too individualistic.4
Callahan discusses a key dimension of social ethics—regulatory and
policy ethics. This aims “to fashion legal or clinical rules and procedures
designed to apply to types of cases or general practices.” For instance,
one goal in bioethics is to develop “legal and policy solutions to pressing
societal problems that are ethically defensible and clinically sensible and
feasible” (Callahan 1995:250, 251). Success in doing so can be seen in the
guidelines developed to regulate the ethics of human experimentation
(Department of Health and Human Services 1991; Sieber 1992). However,
recent US efforts to forge a policy consensus about health-care reform
illustrate the many difficulties of this type of ethical task and the political
entanglements social ethics often entails. Indeed, that debate vividly
illustrates what Elshtain argues is universally true, that “ethical
dilemmas are inescapably political and political questions are
unavoidably ethical” (Elshtain 1995:757). More controversial are reported
plans by third-party payers to provide reimbursement only for
empirically validated or supported treatments (see the efforts to specify
such treatments in the US—Kendall and Chambless 1998; Nathan and
Gorman 1998; Sanderson and Woody 1995; Task Force on Promotion and
Dissemination of Psychological Procedures 1995; for European efforts, see
Grawe et al. 1996; Roth and Fonagy 1996).
The close ties between professionalism and society are another reason
why social ethics is important. Many have argued that the very notion of
a professional is inextricably societal and political. Professions exist “in
order to play certain social roles and to further certain social purposes”
(Bassford 1990: 130), purposes which contribute to the general welfare.
When professionals obtain licensure, they engage in political tasks:
persuading legislators to grant therapists a special status and (perhaps of
more importance) convincing society that psychotherapists possess
distinctive expertise that can benefit all. As Michels notes:
in a sense, a profession can be seen as a group of people to whom
society has delegated power and authority based on the assumption
that they have certain knowledge and skills that are not generally
available and that are required for decisions in a certain area.
(Michels 1991:70)
Kultgen (1988) carefully examines the structure of professions in society.
He considers both the benefits to society of professionalism and the
problems it produces. By doing so, he engages in social ethical analysis.
In addition, Ozar asserts that professional ethics has a societal
dimension. Professional ethics arises, not simply from within the
profession, but from an ethical discussion between professionals and
society members. The professional obligations delineated in codes of
ETHICS 27
professional ethics are “obligations whose content has been worked out
and is continually being affirmed or adjusted through an ongoing
dialogue between the expert group and the larger community” (Ozar
1995:2106). And so, any comprehensive ethical analysis of
psychotherapy, if conducted by professionals, requires social ethics.
Social ethics thus poses questions that broaden the ethical discussion
about psychotherapy. For example, is it right for third-party payers (like
Mike’s HMO) to set limits on payments for psychotherapy sessions? What
are the benefits (and costs) to society of unlimited access to
psychotherapy? Which forms of psychotherapy are most beneficial to
society? Is present access to mental health care just? Does everyone have
a right to receive psychotherapy? To best advance the common good,
what policies should govern third-party payers? Is it good for
psychotherapists to free clients from a sense of moral obligation (from
“shoulds”)? What would be the impact on families (however defined), on
local communities, and on society as a whole if everyone were so freed?
And, more broadly, what should be the role of psychotherapy in society?
When considering social ethical dimensions of psychotherapy, it is
evident that all five dimensions of ethics are intertwined (cf. Callahan
1995). Formulating codes of professional ethics involves professionals
negotiating with other members of society, and so involves questions of
social ethics. Questions about the intellectual warrant for social ethics
require theoretical ethics. Many clinical ethicists stress the importance of
context in addressing clinical issues, contexts which social ethics address.
Most virtue ethicists stress that virtues arise in a social or community
context and contribute to the well-being of a society. Finally, social ethics
is closely tied to cultural ethics.
Cultural ethics
The major difference between cultural ethics and social ethics is that the
former focuses on the critical analysis of culture and the particularities of
various societies. Societies (or cultures) are analyzed and contrasted to
understand the ethical perspectives of other cultures and to learn more
about one’s own. Cultural ethics, according to Callahan (1995), thus
involves relating ethics to broader historical, ideological, and cultural
factors. Such cultural analysis is an essential component of attempts to
understand psychotherapy as a universal, cross-cultural process of
human change. To the extent psychotherapy involves values or ethical
dimensions, the different answers various cultures give to ethical questions
need to be examined.
Cushman (1993, 1995), Hare-Mustin (1994), and others have offered
cogent cultural analyses to illumine the moral discourse and the values
implicit in psychotherapy. Hare-Mustin, for instance, demonstrates how
“there is a predetermined content in the conversation of therapy: that
provided by the dominant discourses of the language community and
28 ETHICS AND VALUES IN PSYCHOTHERAPY
culture.” Through an analysis of such discourses,5 we can learn about
“both prevailing ideologies and marginalized discourses.” She points
out, for instance, that “men’s sexual urges are assumed to be natural and
compelling; thus, the male is expected to be pushy and aggressive in
seeking to satisfy them” (Hare-Mustin 1994:19, 23, 24). By examining such
dominant (and thus often unobserved and hidden) discourses in a
culture, we can see ethical dimensions of therapy that would otherwise
remain occluded. Through an examination of interactions, for example,
between Mike and his therapist (or between the therapist and his male
buddies on the golf course), discourse analysis holds promise for
illuminating implicit ethical assumptions present in a particular culture.
In contrast to US individualism and emphasis on autonomy, African
peoples, in their ethics, emphasize tribal community, family belonging,
and reciprocity (Paris 1995). This echoes Asian Indians’ rejection of the
primacy of autonomy as an ideal for human beings (Varma 1988)
mentioned in the first chapter. Such cross-cultural ethical reflection can
help us to understand our own ethical positions, and is crucial when
therapists work with clients whose cultural values they do not share.
In summary, “ethics” is a rich, multi-faceted term, involving multiple
overlapping dimensions: professional ethics, theoretical ethics, clinical
ethics, virtue ethics, social ethics, and cultural ethics. A full-fledged
ethical analysis of psychotherapy will thus perforce be wide-ranging.
The science-ethics relationship
Because psychology is a science and psychotherapy is often considered
an applied science, any examination of the meaning of ethics requires
consideration of the relationship between science and ethics. Ethics and
science were once sharply distinguished. As discussed in the first chapter,
positivists claimed that we can draw meaningful conclusions only from
scientific thinking and logic; most ethical reflection was accordingly
viewed as meaningless (Callahan 1995; Slote 1995). Because this view was
widely held, Callahan observed that “matters of ethics and values had
been all but banished from serious intellectual discussion” (Callahan
1995:249). And so, ethical positivists would think it meaningless (because
not empirically demonstrable) to assert that it was unethical for Mike’s
therapist to violate Mike’s confidentiality (although we could empirically
establish that many people would judge it harshly or report having
“negative” emotions about it, and that a given percentage of the
population would disapprove of it), that Mike should not lie to his wife,
or that it was wrong for poor inner city residents to be treated unjustly.
As positivism has lost its hold in the philosophy of science and other
disciplines (Edel 1986; Koch and Leary 1992; Robinson 1985; Suppe 1977),
bioethicists, psychotherapists, and other scholars are again giving serious
consideration to ethics (including formulating ethical principles to guide
behavior), without the sharp distinctions drawn by the positivists.
ETHICS 29
Such efforts often cross the steep disciplinary walls erected by the
positivists; philosophers and scientists are again learning from each
another.
In fact, as traditionally conceived, ethics includes an empirical
component. This component “describes actual beliefs and customs”
(Pojman 1995b: 2) and seeks to “describe or explain the phenomena of
morality or to work out a theory of human nature which bears on ethical
questions” (Frankena 1973:4). And clinical ethicists are “actively engaged
in accumulating and developing as rich a set of facts as possible as well
as interpreting them” (Fletcher and Brody 1995:400), a position similar to
that espoused by K.S.Kitchener (1984) for counseling psychologists. The
descriptive methodologies of the natural sciences and other disciplines
can clearly make substantial contributions to such efforts (cf. Tugendat
1990; Waterman 1988). As Frankena noted, “Moral philosophers cannot
insist too much on the importance of factual knowledge and conceptual
clarity for the solution of moral and social problems” (Frankena 1973:13).
Although such descriptive inquiry is frequently distinguished from
theoretical ethical thinking, the two are interrelated, since theoretical
ethics tells us what “counts” as an ethical or moral phenomenon (Brody
1989) and descriptive assertions (especially about human beings) are
required in any ethical theory.
A misconception about the relationship between science and ethics
must be avoided, however. Empirical generalizations do not lead directly
and conclusively to ethical conclusions. Because of the lingering effects of
the positivistic philosophy of ethics, it remains commonplace to assume
that what is “ethical” or “moral” is merely a matter of consensus or
cultural influence. Ethics and morality, on this account, are reduced to
custom (which can be investigated scientifically), to ways in which
societies perpetuate themselves. Ethics thus does not pertain at all to what
is actually right or good. Ethicists, however, commonly distinguish ethics
from custom, consensus, and etiquette (Pojman 1995b; Veatch 1989b):
ethics is characterized by the defensible reasons offered to support the
ethical conclusions drawn.
“Ethics” and related terms
“Ethics” is distinguished from “morality” by some, but the terms are
used synonymously by others. No standard distinction between the
terms exists (Annas 1991; Ladd 1978; Margolis 1966). I will primarily use
the term “ethics” rather than “morality” because the latter often carries
negative connotations, perhaps because of its association with the
negatively-tinged “moralizing” (Cushman 1995:280; Fairbairn and
Fairbairn 1987:9) and “moralistic.” Moralistic is often used to refer to a
narrow, conventional, simplistic, judgmental, or rigid imposition of
ethical principles on others. I will use it to refer to that negative use to
30 ETHICS AND VALUES IN PSYCHOTHERAPY
which some people put ethical principles in their relationships with
others.
To complicate matters further, however, both “ethical” and “moral”
are used in more than one sense. Of the first sense, Frankena notes, “the
terms ‘moral’ and ‘ethical’ are often used as equivalent to ‘right’ or ‘good’
and as opposed to ‘immoral’ and ‘unethical’” (Frankena 1973:5). For
example, “It is ethical to charge a fee for therapy as long as the fee is
reasonable and clients are informed about financial arrangements ahead
of time,” but “It is unethical to violate confidentiality.” However, “moral”
and “ethical” can also be used in a more general sense to refer to
particular types of problems or judgments. Here, the terms refer to that
which pertains to morality or ethics, and have as their opposite
“nonethical.” For example, “confidentiality is an ethical issue” but
“whether to live in Minneapolis or Allentown is a nonethical issue.”
Another important distinction can be drawn between moral and
nonmoral evaluative considerations, with ethics taken as a broad,
overarching discipline that embraces both (Annas 1991). Violating Mike’s
confidentiality, and Mike’s lying to his wife would both be considered
moral issues, for instance, but the preference Mike’s therapist exhibits for
chartreuse cars, and Mike’s love of country and western music would be
considered nonmoral (representing their aesthetic values). Although no
consensus exists about how to properly sunder moral and nonmoral,
Annas describes four traditional distinguishing marks:
(a) a distinction of kind between moral and nonmoral reasons, (b) a
strict demand of responsibility (“ought” implies “can”), (c) the
prominence of duty or obligation as the basic moral notion, and (d)
an essential concern for the noninstrumental good of others.
(Annas 1991:330)
To these Pojman adds the following marks of what is moral:
universalizability (“moral principles must apply to all who are in the
relevantly similar situation”—1995b:7) and overridingness (moral
considerations “trump” those that are nonmoral). And Frankena holds
that moral values must “embody some kind of social concern or
consideration” (1976:126).
The moral-nonmoral distinction is crucial to an ethical analysis of
psychotherapy, in part because it has been used to distance science and
psychotherapy from ethical analysis. In response to the claim that science
is value-laden, some have acknowledged that science properly involves
values (e.g. Laudan 1984; Longino 1990; Popper 1976), but only
nonmoral, scientific values. As I am using “ethics,” however, the analysis
of such nonmoral values is part of the task of ethics.
Psychopathology can also be viewed in terms of the moral-nonmoral
distinction. Mike’s depression would generally be evaluated in nonmoral
terms: he would not (or should not) be considered morally blameworthy
ETHICS 31
(responsible) for being depressed (especially if the depression stemmed
from biochemical abnormalities, from childhood maltreatment, or from a
noxious, controlling, punishing work environment over which he had
little control and to which he had learned to respond as though he were
helpless). By way of contrast, many would argue that he was morally
blameworthy (responsible) for his affairs and for his lies, as his therapist
was morally blameworthy (responsible) for violating Mike’s
confidentiality. Ethics, as I am defining it, applies to both the moral and
the nonmoral aspects of psychopathology.
The moral-nonmoral distinction has also been applied to
psychotherapy, with Hartmann (1960) first espousing the influential view
(see Strupp 1980) that psychotherapy, properly conducted, affects “health
values” (a type of nonmoral values) but not “moral values.” Although I
have argued for a similar distinction (Tjeltveit 1986), I now see some forms
of it as problematic, and the relationship between “moral” and “nonmoral”
in analyzing the ethical dimensions of psychotherapy will need further
exploration in due course, especially in our considerations of ethical
theory in Chapter 4 and of the goals of therapy in Chapter 9. Again,
however, as I use the term, ethics encompasses both moral and nonmoral
evaluative considerations.
My use of “ethics” must also be distinguished from two frequent
misunderstandings of ethics (misunderstandings perhaps partly
responsible for the common lack of interest in ethical analysis among
psychotherapists): limiting ethics to “moral dilemmas” and missing the
subtle ethical implications contained within much psychological language.
“Ethics” is often used to refer exclusively to especially difficult or
subtle issues, like “the ethics of gene splicing.” Such thorny issues
sometimes arise in therapy, for instance, in situations involving
conflicting values. However, “ethical,” as used here, is a much broader
and more fundamental term. It includes such issues as whether it is better
to be guided by general ethical principles (such as autonomy), by the
functional impact of one one’s actions on the well-being of society, or by
the traits (qualities of character, or virtues) therapist and client optimally
exhibit. Those more general ethical issues are regularly faced by clients
and therapists. Indeed, they undergird therapy and shape its discourse.
Another reason why the ethical dimensions of psychotherapy may be
discussed so rarely (and often go unrecognized entirely) is that many of
the evaluative words used by therapists mask those dimensions. For
instance, “healthy,” “well-adjusted,” “appropriate,” “mature,” and
“rational” are terms not only descriptive, but evaluative (primarily
involving nonmoral evaluations). Such words describe characteristics that
are valued, that are considered good or ideal in a person. They thus
provide answers to questions posed for millennia by moral philosophers.
Finally, the relationship of ethics and “values” requires brief mention:
“values” are connected to the concerns of ethics (as discussed in this
chapter) for some people, but not for others. For instance, when Rokeach
(1973) argued that the definition of values should not include the words
“should” or “ought,” words that virtually define “moral” for many, he
32 ETHICS AND VALUES IN PSYCHOTHERAPY
clearly distanced himself from ethics in his empirical investigations of
values. For some philosophers, by way of contrast, values are central to
ethics, with ethics embracing both moral values and nonmoral values.
For still others, investigating “values” permits one to address ethical
issues while being scientifically reputable, and without the interminable
wrangling about ethical dilemmas associated with philosophy. “Values”
is thus a term that bridges the science-philosophy divide.
At one point in history, before psychologists began empirical
investigations of values, “values” was a term associated with one side of
that divide, the philosophical side. Scientists were concerned with facts,
and philosophers with values. To claim to derive values from facts was
seen as fallacious. More recently, however, the strict fact—value
distinction has been attacked on many fronts.6
Taking full advantage of the rich literature on values in psychotherapy
requires teasing out the multiple meanings of values and exploring
further the fact-value distinction. It is to that task that Chapter 5 and a
portion of Chapter 6 will be devoted. Doing so will permit us to obtain
maximum benefit both from the empirical research on the role of values
in therapy and from the theoretical reflection contained in that literature.
It will first be necessary, however, to unpack what I mean by claiming
that psychotherapists regularly and pervasively address issues that are
ethical, that therapists function as “ethicists.”
3
Psychotherapists as ethicists
Engaging in difficult, essential tasks
Mike’s therapist, like most therapists, probably does not consider himself
an ethicist. Furthermore, Mike, like most clients, probably does not think
of his therapist as an ethicist. Indeed, he might not have gone to a
therapist if he thought therapists functioned as ethicists.
People disagree about the meaning of “ethicist.” It is both contrasted
and equated with such terms as moral philosopher, value theorist, and
moralist. All of those terms refer to someone who addresses moral or
ethical issues or values, but they often carry significantly different
connotations about how ethical issues and values are approached. When I
contend that therapists function as ethicists, I am therefore drawing upon
a particular understanding of the meaning of ethicist, an understanding I
set forth in this chapter.
In what follows, I will define ethicist, address the relationship between
that definition and “ethical expertise,” discuss how being professionals
influences (or should influence) the ways in which therapists function as
ethicists, delineate some functions performed by ethicists, and describe
the variety of ways in which psychotherapists function as ethicists.
Definition
By ethicist, I mean a person who reflects on, has convictions about, and/
or attempts to influence others about ethical questions and issues. That
some people perform such ethical tasks problematically is disputed by
few; whether some people perform ethical tasks especially well is more
controversial.
I will use “moralist” or “moralizer” to refer to those who attempt to
impose values on others, who are concerned with regulating the moral
lives of others, or who simply tell other people what to do. This is often
done in an excessively narrow, conventional, and authoritarian way. The
moralist or moralizer is thus moralistic and engages in moralizing with
others. This distinction between ethicist and moralizer is not, of course,
an absolute one. Ethicists fall on a continuum, varying in the specificity
and rigidity of their ethical stances and the extent to which they uphold
34 ETHICS AND VALUES IN PSYCHOTHERAPY
the freedom of others to make ethical decisions. Accordingly, ethicists,
including psychotherapists, exhibit varying degrees of moralism.
If moralizers exemplify a problematic approach to ethics, perhaps
others address ethical issues especially well. That is, some persons may
possess ethical expertise. If that is true, understanding ethical expertise
can provide us with important insights about how psychotherapists can
perform ethical tasks well. But some people deny the existence of ethical
expertise.
Can ethicists possess ethical expertise?
Professionals are expected to be competent in what they do. Indeed,
professional codes of ethics mandate that professionals limit their
practices to their areas of competence. But what does it mean to possess
competence or expertise in the arena of ethics? And do psychotherapists
possess such expertise?
Veatch has suggested that physicians, by virtue of their expertise in the
medical realm, are often considered to possess expertise in the realm of
medical ethics—by “generalization of expertise” (Veatch 1973:29).
Likewise, some think that psychotherapists, by virtue of their expertise
with mental health problems, have expertise with related ethical issues,
by generalization of expertise. Can that claim be justified?
Some assert that—given the “subjectivity” or “relativity” of ethics—the
very idea of ethical “expertise” is meaningless. Indeed, Caplan (1989)
points out that there are good reasons for being skeptical about claims to
ethical expertise. And some conceptions of ethical expertise—that the
moral judgments of certain ethicists are infallible or that some ethicists
never make mistakes in matters moral—seem extremely difficult to
justify.
More defensible definitions of ethical expertise exist, however. To
address whether it is legitimate to talk about ethical expertise or
competence, however, we need to be clear about the meaning of that
phrase. Three meanings of “ethical expertise” may be distinguished:
1 Ethical expertise arises when society considers certain persons to have
expertise or treats them as though they do.
2 Ethical expertise is a function of advanced education, requiring a
Ph.D. or extensive advanced course work in ethics, moral philosophy,
or value theory.
3 Expertise exists when ethicists either make correct ethical judgments
or make coherent, rational arguments for ethical positions.
According to the first usage, experts have expertise because society, or
some segment of society, says they do, or treats them as though they do.
And so Rieff (1959), for instance, analyzed how society has been
influenced by psychoanalysis because psychoanalysts (following Freud,
PSYCHOTHERAPISTS AS ETHICISTS 35
“the moralist”) have come to be regarded (in a process Rieff (1966) calls
“the triumph of the therapeutic”) as expert at tasks that are moral in
nature. Because of the respect accorded therapists in society, they function
as experts. What is critical, in this usage of “expertise,” is not the grounds
that are used to determine whether someone has expertise, for instance,
ethical correctness, sound argument, or advanced training. What is
critical is that at least certain segments of society interact with some
persons as though they have expertise.
Although it is important to recognize that at least certain segments of
society believe or act as if such “experts” exist (and so the first usage of
“expertise” is valid), that fact does not settle the question of whether
advanced training should be a prerequisite for the honorific title
“expert,” or whether such persons should be considered ethicists, possess
better values, or reason better about ethical issues. Society may well grant
its imprimatur on some persons for inadequate, poorly thought out, or
incorrect reasons.
And so we need to consider whether we are justified in considering
some persons to have especially worthy answers to ethical questions. An
answer to this question can clarify whether the meaning of “ethicist” can
involve ethical expertise.
Which persons warrant the honorific title “ethicist”?
In keeping with the first understanding of “ethical expertise,” some
would define “ethicist” as follows: anyone to whose answers to ethical
issues society (or some segment of society) gives particular heed. But by
this definition, Adolf Hitler and Jim Jones would be considered to have
ethical expertise, and to be ethicists, because they held particular moral
views to which others gave particular heed. However, most who would
grant Hitler and Jones the status of “ethicist” would consider them bad
(or even evil) ethicists. If we aspire to a definition of “ethicist” with
positive connotations, we need a richer meaning of “ethical expertise.”
Doing so requires the development of reasons for attributing expertise to
certain persons.
Some argue that “ethicist” should be restricted to persons with formal
philosophical training in ethics, moral philosophy, or value theory.
Addressing ethical issues is their central professional objective and
expertise. Macklin, for instance, points to particular reasoning skills at
which philosophers excel, including “conceptual analysis, illustrating
subtle distinctions between facts and values, clearing up ambiguities in
key terms, and pointing out flaws in reasoning” (Macklin 1989:119).
On that understanding of ethical expertise, society could only
appropriately give the honorific title “Psychotherapist as ethicist” to
those rare individuals with advanced training both in philosophy and in
one of the psychotherapeutic disciplines.
36 ETHICS AND VALUES IN PSYCHOTHERAPY
Limiting “ethicist” to those with advanced training in ethics is
consistent with reserving the term “psychologist” to those with advanced
training in psychology or “medical doctor” to those with advanced
training in medicine. This approach rests upon the assumption that the
divisions between disciplines and professions correspond to discrete
functions, so that lay people (those without specialized, advanced
training) in no way function as physicians, psychologists, or professional
ethicists.
However, the divisions between professional roles set out in the
academy or by governmental licensing boards may not always function
as they are supposed to. “Lay” people in fact attempt to address physical
health problems—sometimes disastrously and sometimes well. Likewise,
the professional bioethics consultant on a neonatal intensive care unit
functions in part as a psychologist of sorts (assessing family functioning
and intervening to decrease distress) when interacting with family
members about dilemmas such as terminating life support, dilemmas
that are at once medical, familial, emotional, and ethical. Hence, lay
people do, in some genuine sense, “practice medicine.” And ethicists
“practice psychology.” De facto functions may thus not be coterminous
with de jure professional distinctions.
Furthermore, professional training does not prevent errors in one’s
area of expertise. The training that Mike’s therapist received did not
insure his competence: he failed to detect and treat Mike’s alcohol abuse,
and committed an infraction of professional ethical standards by
violating Mike’s confidentiality. Although he possessed the requisite
formal training and was undeniably a therapist in the eyes of a state
licensing body, in light of those lapses, few would argue that he
possessed exceptional expertise as a therapist. Or even that he was a good
therapist. Likewise, someone may have professional training in ethics yet
draw faulty logical conclusions or endorse ethically problematic views.
By way of contrast, some people who lack formal training in ethics may
reason very well about ethical issues (Meehl 1981) or otherwise address
ethical questions well.
And so if we strive to define an ideal ethicist, we need a substantive
concept of ethical expertise. Caplan argues for such a concept, one not
limited to those with advanced philosophical training:
Expertise in ethics appears to consist in knowing moral traditions
and theories. It also involves knowing how to apply those theories
and traditions in ways that fruitfully contribute to the
understanding of moral problems. But, most importantly, ethical
expertise involves the ability to identify and recognize moral issues
and problems, a skill that may be enhanced by training in ethics,
but one that is not by any means restricted to those who have this
training or that is beyond the intellectual capacities of those who do
not have this training.
(Caplan 1989:85)
PSYCHOTHERAPISTS AS ETHICISTS 37
If one were to hire an ethicist, one would undoubtedly seek someone
with such expertise. And if therapists function as ethicists, and ethicists
have the potential to develop such ethical expertise, then it is incumbent
upon therapists to insure that they possess or develop that competence.
Professional philosophy may play a role in the development of such
expertise, in the development of the ideal ethicist, but formal training in
philosophy is not essential for such expertise (Baylis 1989; Caplan 1989).
Accordingly, I will draw upon the thinking of philosophers, but without
presuming that their answers to the ethical issues that psychotherapists
address are necessarily the best answers.
Advanced training in philosophy may not be the only kind of
advanced training that helps to address the specialized ethical issues
involved in psychotherapy, however. Advanced training in
psychotherapy may also be beneficial. While acknowledging that facts
derived from scientific investigations do not give mental health
professionals ethical expertise, Michels argues that scientific knowledge:
may make possible the life experiences which can lead to a
refinement of ethical sensitivities. For example, the physician has no
special claim to skill in deciding who shall live or who shall die
because of his knowledge of anatomy or physiology. However, his
knowledge of these fields may have led him to an unusual amount
of experience in caring for dying people and may have allowed him
that special privilege and responsibility of making scientific or
technical decisions which lead to life and death results. Experiences
such as these can lead to ethical expertise.
(Michels 1991:70)
This suggests (again in parallel with recent developments in bioethics)
that psychotherapists may best develop ethical expertise, and become
optimally
effective
psychotherapist-ethicists,
if
we
mount
interdisciplinary efforts (Callahan 1995) related to the ethical dimensions
of psychotherapy.
Let me recap my argument thus far. In order to explore most fully the
functioning of all who address ethical issues, I will use “ethicist” in a
broad sense to refer to both professional/academic ethical experts and lay
persons who address ethical issues. I will reserve the terms “moral
philosopher,” “value theorist,” and “philosophical ethicist” for
professional or academic ethicists.
I assume that all psychotherapists are ethicists, but not all are “good”
ethicists; that is, not all reason well, or provide optimal answers to ethical
questions. Therapists can benefit from dialogue with professional
philosophers, and their ethical expertise is likely to increase as a result.
But the philosophical ethicists with whom they discuss those issues need
dialogue as well—with psychotherapists—so they can fully understand
the ethical dimensions of psychotherapy.
38 ETHICS AND VALUES IN PSYCHOTHERAPY
Psychotherapists functioning as ethicists employ the full range (all six
dimensions) of ethics discussed in Chapter 2. Psychotherapists
functioning as ethicists engage primarily in clinical ethics, but doing so
optimally requires theoretical ethics as well, and hence may benefit from
the expertise of professional philosophers. And good therapists can be
thought to possess certain professional virtues. In addition, the fact that
psychotherapy occurs within a broader social and cultural context means
that psychotherapists address issues of social and cultural ethics. Finally,
professional ethics sets limits on how psychotherapists function as
ethicists.
Professional ethics and limits on the nature of
therapeutic interactions
Codes of professional ethics limit the freedom of therapists to influence
client values, and thus affect all of the various roles in which a
psychotherapist functions as an ethicist. Psychotherapists who interact
with clients moralistically, condemning those who disagree with them,
are behaving in violation of codes of professional ethics. The underlying
ethical principle is that psychotherapists should have a special kind of
relationship with their clients, one characterized by disinterest and
beneficence. “Disinterest” (in this sense of the word) does not mean a lack
of interest in the client, but being primarily concerned with the client’s
(not the therapist’s) needs. Therapists who act in a professionally
responsible manner will strive to be objective rather than biased. Further,
they will be primarily concerned with client well-being rather than their
own interests. And they will grant to clients a substantial measure of
freedom to choose the values they wish, rather than imposing their
values on clients. That is, professional therapists will exhibit beneficence.
The ethical principles of the American Psychological Association, for
instance, state that “psychologists seek to contribute to the welfare of
those with whom they interact professionally” (APA 1992:1600).
Similarly, A.L.Caplan notes that:
the threat of abuse or error is so great that the social role assigned to
moral experts or those with moral expertise must be confined to the
tasks of exhortation and giving advice. Society should not create an
elite of moral experts who have the authority to impose their
judgments on others.
(Caplan 1989:74)
Hence, the psychotherapist’s influence is limited in some ways by virtue
of being a professional, limited in ways discussed in greater detail later in
the book. For example, as an ethicist, the therapist will respect the
autonomy of others, will address the ethical aspects of a situation
PSYCHOTHERAPISTS AS ETHICISTS 39
primarily by raising questions and presenting options and, if an attempt
is made to influence clients, will do so with reasoned argument and in a
way which clearly upholds the client’s right to dissent. The concept of the
professional thus carries within it standards that guide (and limit)
professionals as they work with clients.
The roles of the ethicist
In asserting that ethicists reflect on, have convictions about, and/or
attempt to influence others about the ethical aspects of practical
situations, I am suggesting that ethicists perform multiple roles. When
psychotherapists function as ethicists, they may be engaging in one or
more of those roles. These variegated functions require further
explication.
Reflecting about ethical issues
Psychotherapists and others reflect on ethical issues in a variety of ways.
The ideal: psychotherapists think well about ethical issues, think clearly,
analytically, consistently, and coherently. Therapists will avoid, for
instance, the fourteen cognitive errors (e.g. inconsistency) that Meehl
(1981) noted may be present in a person’s ethical convictions. When an
ethical question arises, the facts and context of the situation need to taken
into consideration. And A.L.Caplan’s (1989) concept of ethical expertise
applies: thinking well about ethical issues will be aided by an
acquaintance with the history of other attempts to address the questions
with which the ethicist is wrestling. For a therapist functioning as an
ethicist, that may mean careful reflection on what other therapists have
argued are worthwhile (“good”) goals in therapy, on what moral
philosophers across the millennia have had to say about ethical matters,
or, best, on what both sets of traditions can contribute.
Ethicists exhibiting excellence in reflection on ethical issues, according
to Ruddick and Finn, provide “a wider range of principles and categories
and a sharper eye for self-serving presuppositions and implicit
contradictions,” and the ability to provide a “clear description of moral
aspects and reasons” (Ruddick and Finn 1985:42, 45).
Accordingly, a therapist reflecting on Mike’s situation may focus solely
on the means necessary to reduce his depression (that is, to bring about
the nonmoral good of decreased depression). Or, in a more detailed,
more adequate ethical analysis, the nonmoral good of Mike’s decreased
depression may be balanced against moral concerns about his lying and
infidelity. If Mike’s therapist were to engage in careful moral reflection
about his own behavior, he might balance the nonmoral good of bonhomie
with his friends on the golf course against several other ethical issues:
violating the promise he made to Mike to preserve confidentiality,
40 ETHICS AND VALUES IN PSYCHOTHERAPY
violating his own profession’s code of ethics, violating the law governing
client privilege, and the potential harm (negative, “non-good”
consequences) of violating Mike’s confidentiality (e.g. if Mike’s moralistic
boss fires him after learning of his affairs). Such ethical reflection may
clarify a therapist’s course of action.
Holding ethical convictions
Ethicists holding particular ethical convictions may believe, for instance,
that it is good to express one’s feelings, to be assertive, honest, rational, or
creative, to remain faithful to one’s spouse so long as that commitment is
freely chosen and meets one’s needs in the moment, and so forth. They may
believe that it is right to tell lies in certain circumstances, to put one’s own
needs ahead of those of others if health is thereby achieved, to have one’s
sexual needs met even if that involves violating societal strictures, or to
do anything so long as one has chosen to do so authentically and no one
else is harmed. Or they may believe that it is virtuous to be honest, to treat
others justly, or to be healthy.
Sometimes ethical convictions are limited (minimalist) and sometimes
very extensive (maximalist). Meehl, for instance, describes himself as a
“moral minimalist” (1989:370), that is, employing a limited set of ethical
principles (cf. Callahan 1981 for a critique of moral minimalism).
Convictions may be present at the level of particular values, for
example, “It is good to be assertive.” They may also be present at the level
of ethical theory (discussed in Chapter 4), for instance, the belief that it is
meaningless to talk about ethical obligation, or that there are objective
moral standards to which intuition has access. In evaluating the
appropriateness of an act, one ethicist may focus on its consequences; a
second may hold that certain acts are right or wrong regardless of their
consequences (e.g. “incest is wrong whether or not damage to a child can be
discovered.”).
The ethical principles that appear to have guided Mike’s therapist were
the centrality of the nonmoral good of reduced depression and the
importance of honoring clients’ therapy goals. He either did not regard
Mike’s infidelity and lying to be ethically problematic, or his convictions
about the proper role of the therapist (what a good therapist does, or
what a therapist should do) led him to believe that those issues were
beyond the purview of therapy, of brief therapy, or of therapy in which
Mike did not label those issues as problematic.
Influencing others
Therapists functioning as ethicists may also strive to influence others. Or
they may influence others although not intending to do so. Again, the
scope and manner of this influence vary extensively.
PSYCHOTHERAPISTS AS ETHICISTS 41
In their relationships with clients, many psychotherapists strive to
minimize their influence on client values. That is, they put aside or
“bracket” their ethical convictions (save those intrinsic to therapy itself),
often striving to work within the client’s own moral framework (as a way
of exhibiting beneficence). But when working with clients whose moral
convictions are extensive and life-pervasive, some therapists may be
tempted to influence such clients to “loosen up.” In that kind of
subtractive ethical influence, therapists strive to reduce client adherence
to particular ethical views. By way of contrast, therapists engaging in
additive ethical influence strive to get clients to adopt a particular ethical
view (e.g. to adopt the view, “it is good to seek pleasure for oneself’).
Those who are ethical agnostics (unsure about their ethical convictions)
may either accept clients’ ethical convictions or strive to influence clients
to decrease their allegiance to both strongly held positive ethical views
(“I should strive to eliminate poverty and injustice”) and strongly held
negative views (“I should not have lustful thoughts about my married coworker”). Wallace sees a danger in absolute perspectives of any stripe.
And so he sees an “ever-present need to rein the human quest for
certainty, lest it lead to ‘positive’ or ‘negative’ absolutisms, to dogmatism
or skepticism respectively” (Wallace 1991:75). Albert Ellis’s vehement
rejection of all “shoulds,” an absolutism ironically cloaked in rhetoric
abjuring all absolutism (in favor of the ideology he labels “rationality”),
vividly illustrates the latter.
Therapists may influence client ethical views and behavior in several
distinguishable ways: ethicists may function as teachers, consultants,
coaches, advocates, role models, and midwives.
An ethicist may teach others about ethics. This may mean teaching
people how to think well about ethical issues, teaching the full range of
what others believe to be the correct answers, teaching what the ethicist
believes to be the right answers, or some combination of those roles.
Some teachers simply proclaim the “right” answers and expect students
to parrot those convictions. However, a person would generally be
considered a good teacher only if he or she, while teaching the content of
various traditions and taking occasional stands, sees as primary the
obligation to help students arrive at their own ethical conclusions, wellreasoned and in dialogue with ethical traditions, that is, to teach students
to reflect well ethically.1 As Agich puts it:
Knowledge of ethical concepts, principles, and theories certainly
serves to organize one’s observations and judgments, but the
primary goal is not to teach those concepts and principles in some
theoretically sophisticated way; rather, the goal is to develop skills
of judgment such as identifying the relevant ethical aspects of the
case and the ethically acceptable options.
(Agich 1990:390)
42 ETHICS AND VALUES IN PSYCHOTHERAPY
The ethicist may also strive to influence others in the role of
consultant. Consultants, who presumably possess some relevant
expertise, provide an independent evaluation of a situation. They
generally make recommendations that the consultee has the right to
accept or reject. Sometimes those recommendations are made directly, but
consultants may also frame situations so that the consultee will likely
choose what the consultant thinks best without the consultant being
overt about his or her convictions. Finally, the consultant may, in light of
the consultee’s goals, simply set out a spectrum of workable options and
leave the final decision to the consultee.
In the bioethics literature, discussions of ethics consultants primarily
refer to philosophers consulting with physicians about the ethical
decisions physicians must make (Agich 1990; Fletcher and Brody 1995).
But the psychotherapist can also serve as an ethics consultant, consulting
with clients about the ethical dimensions of their lives, including
balancing the nonmoral goods of optimal psychological well-being with
other ethical principles. Although therapists may not see themselves as
playing the role of ethical consultant, clients seeking help for complex life
problems often look to their therapists for answers to problems that
intermingle mental health2 and ethical issues.
Suppose Mike had said to his therapist: “I just don't know what to do.
Some of the time I love my wife, and feel like I should be faithful to her.
But I get so mad at her, and these other women are so beautiful, and it’s
so exciting to be with them. But then I feel bad, deceiving my wife. I feel
guilty about that, and then I get depressed. I just don’t know what I
should do. What do you think?” In that situation, Mike has given his
therapist permission to serve as an ethical consultant, a role that must be
balanced with other roles (which may also involve ethical issues to some
extent).
Psychotherapists may also function as coaches of the ethical
dimensions of clients’ lives. The therapist/coach equips the client/athlete
with the skills necessary to reach an agreed-upon goal. Beginning with
the client’s existing skills, therapists give practical guidance and direction
so the client can function at the highest level possible. Mike’s therapist, for
instance, coached Mike on how to decrease his depression (a nonmoral
good) by challenging his depressogenic habit of using “should
statements.” He employed subtractive ethical influence to reduce the
salience of Mike’s moral compunctions against cheating on his wife and
lying.
Ethicists may also advocate certain ethical positions, setting forth
reasons in support of those views, asking questions likely to lead others
to adopt those positions, or otherwise persuading others to adopt their
ethical perspectives. Doherty illustrated advocacy in his work with a
client whose wife had ended their marriage. The client was
contemplating leaving the region, which would have effectively ended
his relationship with his two young children. In the context of a strong
therapeutic alliance, Doherty decided to “challenge him in explicitly
PSYCHOTHERAPISTS AS ETHICISTS 43
moral terms….I gently but forcefully told him that I was concerned that his
children would be damaged if he abandoned them” (Doherty 1995:22).
The therapist explains the reasons for his ethical views (thereby engaging
in theoretical ethics) as follows:
I consider commitment the moral linchpin of family relationships. It
is more than a private, idiosyncratic value that I may or may not
choose to promote in therapy. To maintain professional integrity, I
believe I must bring this moral value to bear in the therapy I
provide and in my teaching and supervision.
(Doherty 1995:24–5)
Likewise, Cushman argues that “because of the intersecting traditions of
my life, I value certain moral concepts, and I want my work as a
psychotherapist to reflect those concepts” (Cushman 1995:289). He lists
several: mutual respect, cooperation, caring, enjoying and cherishing life,
and honoring cultural differences. For Cushman, moral influence is
central to the therapeutic endeavor:
It is the job of the psychotherapist to demonstrate the existence of a
world constituted by different rules and to encourage patients to be
aware of available moral traditions that oppose the moral frame by
which they presently shape their lives.
(Cushman 1995:295)
A subtler form of influence is the psychotherapist’s function as role model.
A client may surmise the therapist’s ethical convictions or observe the
therapist’s behavior (with some distortion likely whenever clients
surmise and observe) and strive to emulate the therapist’s ethical
convictions or behavior.
Finally, the ethicist may seek to influence others in the ethical sphere as
a midwife influences others, by assisting in what is believed to be a
natural process, a process through which something within an individual
emerges. A client’s own values will emerge in the context of the proper
therapeutic relationship, advocates of this position believe. And we can
be confident that these values will be “natural” and, hence, “good.”
Individual differences
Psychotherapists differ widely in how they function as ethicists. The
ethical aspects of Mike’s treatment, for instance, would have been
addressed differently by other therapists. And Mike’s therapist might
function differently with other clients. Furthermore, therapeutic
relationships can be analyzed from a variety of ethical perspectives. The
44 ETHICS AND VALUES IN PSYCHOTHERAPY
existence of those differences is one reason the topic of this book is so
challenging. In this section, I want to delineate briefly some of those
individual differences. Because many correspond to the various
dimensions of ethics and the various roles of ethicists, this will serve to
summarize Chapters 2 and 3.
To varying degrees, psychotherapists address issues that fall within the
purview of professional ethics, theoretical ethics, clinical ethics, virtue
ethics, social ethics, and cultural ethics. The predominant focus of most
therapists is clinical ethics, with professional ethics also shaping their
practices. Issues of social ethics have come to the fore in recent years as
therapists have become concerned about managed care organizations
interjecting themselves into what used to be the privacy of the
therapeutic relationship. And the internationalization of psychology and
growing concern about effective treatment of ethnic minorities have
raised questions of cultural ethics.
The three roles of the ethicist discussed in this section are also
emphasized by therapists in disparate ways. Therapists vary in the extent
to which they reflect on ethical issues, have ethical convictions, and
influence client values. They also differ in the ways in which they engage
in those tasks.
In reflecting on ethical issues, therapists can be unconscious or
otherwise unaware of their function as ethicist and their ethical
convictions, or they can reflect on them consciously. They can adopt
uncritically what parents, religious bodies or traditions, culture,
professors and supervisors, or professional colleagues assert about
ethical issues, they can rebel against those ethical sources, or they can
rationally reflect on what they believe. And such rational reflection can
occur either in isolation from, or in dialogue with, a particular ethical
community and/or the history of ethical deliberation.
We can also contrast the ethical convictions of psychotherapists on the
dimension of ethical minimalism versus maximalism. Some have
extensive sets of ethical commitments; others have few or no ethical
convictions.
With regard to influencing clients, therapists vary in the extent of their
efforts to influence client values: Some adhere to the traditional view and
strive to affect client values minimally; others more readily introduce
ethical concerns. Cushman (1995) and Doherty (1995) may represent a
trend toward more conscious ethical influence, though they are far from
advocating the view that moral influence should be a central goal of
therapy. In terms of how such influence is attempted, therapists can
function in ways similar to teachers, consultants, coaches, advocates, role
models, and midwives.
Some therapists address ethical issues in the same way across all
therapeutic relationships; others continuously tailor their handling of
ethical issues to particular clients’ needs, circumstances, dynamics, and
behaviors. To examine only one therapeutic relationship involving a
PSYCHOTHERAPISTS AS ETHICISTS 45
therapist of the latter type would produce a misleading understanding of
that person’s functioning as an ethicist.
Finally, therapists differ in the expertise they possess regarding ethical
issues, along all three dimensions of expertise I have discussed.
Society assumes psychotherapists have ethical expertise to varying
degrees, paying more heed to therapists when they speak to some issues
than when they speak to others.
If ethical expertise is understood in terms of advanced education in
ethics, moral philosophy, or value theory, few therapists have ethical
expertise. Although a few have studied ethics formally or read in the area
of moral philosophy, most have likely not been formally exposed to the
discipline of ethics.
The quality of the reasoning therapists employ in their reflections on
ethical issues also varies. And so, regarding this and the following
dimension of individual difference, some would want us to speak of
psychotherapists who function as good ethicists. That is, some are willing
to evaluate the quality of a psychotherapist’s functioning as an ethicist.
From the perspective of some ethical communities or
psychotherapeutic perspectives, judgments about the quality of a
therapist’s ethical reasoning would be based on the content of their ethical
thinking, on the particular answers they give to ethical questions. Some
humanistic psychologists, for instance, stress self-actualization as the
highest good for human beings or the central human virtue. By way of
contrast, as noted earlier, African peoples tend to stress tribal
community, family belonging, and reciprocity (Paris 1995).
And so various psychotherapists, in functioning as ethicists, call upon
different ethical traditions and give different answers to ethical
questions. That is, their values, concepts of virtue, and ethical theories
differ. Values will be discussed in Chapter 5 and virtues in Chapters 8
and 9. It is to a discussion of ethical theory that I now turn.
Part II
Intellectual tools for examining values
and ethical theory in therapy
Assumptions and criteria for analysis
and decision-making
4
The spectrum of ethical theories in
psychotherapy
When a psychotherapy client asserts that he cannot possibly disagree
with his boss because that would be “disrespectful,” or when a therapist
argues that rape is wrong, we can analyze those assertions in terms of
theoretical ethics. In doing so, we explore various aspects of the intellectual
grounding for ethical assertions, actions, or character.
In this chapter, I will address several dimensions of ethical theory (also
known as theoretical ethics, philosophical ethics, or moral philosophy): is
it meaningful to use such terms as “respect” and “wrong”? is it rational to
do so? if we decide that meaningful assertions about goodness, rightness,
and virtue are possible, on what basis can we make such ethical
assertions? what reasons or principles do we use, should we use, when we
make ethical decisions? how do we know what is good, right, or
virtuous? for instance, how do we know that it is good to respect others or
wrong to rape? and, finally, in what relationship do issues about
goodness, rightness, and virtue stand to religion?
I address these questions despite the fact many therapists think them
unanswerable. And some think discussion of them is guaranteed to
promote dissension and to divert energy from the more important
activities of research and practice. I address ethical theory in this chapter
for three major reasons: so therapists can be better therapists, so
therapists can be better ethicists, and so all of therapy’s stakeholders can
better work together to understand therapy, improve it, and establish its
optimal role in a society.
As the case below should make clear, optimal assessment and treatment
of clients requires, in at least some circumstances, an understanding of
the reasons they hold particular values. If we do not know, for instance,
that an ethnic minority member’s sense of obligation to family is rooted
in a particular understanding of reality and truth, we may not be able to
understand or work with that individual optimally.
A familiarity with ethical theory can also help psychotherapists
become better ethicists (and thereby better therapists). In terms of the
definition of ethicist I introduced in Chapter 3, knowing ethical theory
can help therapists reflect well on ethical theory (reflecting on clients’
ethical theories, the therapists’ own ethical theories, and ethical theories
that underlie therapy theories, practices, and social arrangements),
48 ETHICAL THEORIES IN PSYCHOTHERAPY
develop and articulate more sophisticated and adequate convictions
about ethical theory, and optimally influence clients with regard to ethical
theory.
Reflecting well about ethical theory means developing a greater depth
of understanding of the ethical dimensions of psychotherapy. A sole
focus on specific values (e.g. “Racism is wrong”) or virtues (e.g.
“honesty”) is sometimes not enough. We often need to know why clients
or therapists hold particular values, the arguments they provide
(explicitly or implicitly), the reasons for holding ethical beliefs. Ethical
theory addresses that more fundamental level of analysis.
Of greatest importance is the fact that an understanding of ethical
theory can help therapists better understand clients. If we understand the
reasons a client holds a particular value, we can provide therapy within
the client’s ethical framework or, with due caution, work with the client
to change a problematic ethical theory. But because clients hold a wide
variety of ethical theories, working within the framework of their ethical
theories requires knowing about the broad spectrum of possible ethical
theories.
In contemporary culture, therapy as a social practice entails particular
answers, or particular sets of answers, to the questions of theoretical
ethics. Familiarity with ethical theory in general permits more rigorous
thinking about those questions and the answers ethicists (from the preSocratics to the various postmodernists) have proposed. That permits us
to develop a better understanding of the ethical character of
psychotherapy in general.
Finally, therapists, like other people, function on the basis of (implicit or
explicit) answers to the questions of theoretical ethics. Psychotherapy is
not simply value-laden; it is also laden with ethical theory.
Psychotherapists’ ethical theories may simply reflect uncritically what
was taught them by parents or supervisors. But I assume it is better that
therapists function with examined ethical theories rather than
unexamined.
Indeed, a central theme in the professional literature concerning
therapy’s value-ladenness is the need for therapists to be aware of their
own values (e.g. Adleman 1990; Corey et al. 1993; Lakin 1988). But I can
be aware of the particular values I hold without being aware of the
reasoning that lies behind them, or of alternative ways of thinking about
ethical issues. Knowledge of ethical theory can increase self-awareness
about that underlying level of ethical theory. That self-awareness makes
it more likely that I will deal respectfully and efficaciously with clients
whose answers to the fundamental questions of ethical theory are
different from my own.
Being able to reflect well about ethical theory can also help us better
understand ethical dilemmas that arise within therapy clients, within
therapeutic relationships, within the psychotherapy professions, and
within a society (especially concerning the role of therapy in the society).
The role of therapy in society, to be addressed in Chapter 10, is in a state
of transition in the US, as managed care stakeholders come into conflict
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 49
with therapists and clients who sometimes employ different ethical
theories.
Ethical theory can also help therapists develop and articulate more
sophisticated, more adequate ethical convictions. Kitchener (1980a) and
Bergin (1980a) assert that individual therapists need to justify the
particular values they hold, to explain why they believe what they believe.
That task involves ethical theory. Furthermore, therapists and others need
to develop better ethical theories (Prilleltensky 1997), for instance, theories
that avoid narrowness and take into account the wisdom contained in
alternative ethical positions.
In addition, knowledge of ethical theory should permit therapists to
become better ethicists by making it easier for them to influence clients in
the most ethical manner. This means in part that therapists avoid
influencing the ethical convictions of clients in ways that are untoward
(Tjeltveit 1986). If therapists convert clients to their values, and there is
evidence that they sometimes do (Beutler and Bergan 1991), it may also
be the case that, as Bandura put it, “clients have been…converted to the
belief system, vernacular, and interpretations of reality favored by their
respective psychotherapists” (Bandura 1969:81–2). In most instances, I
think it inappropriate, indeed unethical, for therapists to convert clients
to therapists’ own ethical theories. Therapist influence on fundamental
client beliefs is far more likely to be appropriate, however, if therapists
are aware of their clients’ ethical theories and their own.
Finally, improved ethical theory should permit psychotherapists to
articulate more effectively what the role of psychotherapy in a society
should be. Because psychotherapists receive reimbursement and other
forms of public support, public accountability to therapy stakeholders is
essential. Justifying the trust the public places in therapists (and justifying
the reimbursement therapists receive) requires effectively articulating
why psychotherapy is good and right, and what its proper limits should
be. Ethical theory can help us to do so.
In this chapter, then, I will explore some aspects of ethical theory
pertinent to psychotherapy. In doing so, I do not purport to add a new
element to therapy, but rather to shed light on aspects of therapy hitherto
obscured.
This is, of course, an exceedingly complex task, for at least two reasons:
philosophers are deeply divided on how best to think about ethical
theory (see Stout 1988); and the ethical convictions, virtues, and
behaviors of clients and therapists inevitably consist of some combination
of psychological factors and considered beliefs. As Margolin notes, a
therapist facing an apparent ethical conflict regarding roles in a marriage
must sort out “whether the conflict regarding roles reflects vastly
divergent ideological positions or whether the ideological differences are
accentuated by relationship issues” (Margolin 1982:798). A comprehensive
understanding of the ethical character of psychotherapy would thus
require a consideration both of ethical theory and of the sort of
sophisticated transdisciplinary moral psychology now rapidly being
developed (e.g. Deigh 1992; Flanagan 1991; Flanagan and Rorty 1990;
50 ETHICAL THEORIES IN PSYCHOTHERAPY
M.Johnson 1993; Kendler 1992; L.May et al. 1996; Platts 1991; Thomas
1989; Wren 1990).
This chapter is more limited in scope: I will provide a brief review of
ethical theory, presenting some major questions which ethical theory
addresses, and some approaches to answering those questions, those I
think most relevant to therapy.
To ground this discussion of ethical theories, consider the following:
Sandra picks nervously at her sleeve. “He got really mad at me last
night,” she says. “I told him I had to go see my Dad. And then he
just blew up. I remember the exact words José used. I keep going over
them in my head: ‘What do you mean, you “should” go see your
father? What about my needs? I’m the man of this house. You
married me, not your father. And we agreed that I am the head of
this household.’”
Sandra sighs deeply and continues, “I get so torn up about it. I
mean, I want a good marriage, but I really do need to go see my
father. He’s not doing very well, and just my being there really
cheers him up. I feel so badly when I don’t go visit him, so
incredibly guilty. It’s my obligation as a daughter. And I simply can’t
have his next-door neighbor think I’m neglecting him—that would
just be awful! I know I should be a good daughter. But when I try to
be a good daughter, José tells me I’m being a bad wife. And I want
to be a good wife. I guess I could have stayed home. We’re
renovating our kitchen. We both really want it looking nice. But I
would have felt too guilty if I’d stayed home.”
Her therapist, Tania, responds warmly, congruently, and
empathically, “So you would have felt too guilty…” An intern in
the second month in this placement, Tania conceptualizes Sandra’s
problem to be low self-esteem. If Sandra could get in touch with her
own feelings and feel better about herself, she would begin to
improve, no longer living by the conditions of worth that make her
feel so “awful.” She needs to become a fully functioning person,
casting off externally derived shoulds, and all external authorities.
Tania recalls reading with enthusiasm from Rogers’ On Becoming a
Person, “Neither the Bible nor the prophets—neither Freud nor
research—neither the revelations of God nor man—can take
precedence over my own direct experience” (Rogers 1961:24). And
so Tania helps Sandra get in touch with her feelings.
Tania discusses Sandra with her supervisor, Dr Schwartz. She
reviews the case: Sandra’s presenting complaint was the sudden
onset of a significant fear of public speaking. Because she works in a
public relations firm, the fear was causing significant occupational
impairment. The phobia began when Sandra was told to provide
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 51
“less than full disclosure” to the press about a client corporation’s
pollution of a local stream. Early therapy sessions focused on her
work-related fears. But those faded from view as Tania responded
to Sandra’s marital conflicts and guilt.
Dr Schwartz, who describes himself as a feminist RationalEmotive therapist, focuses on how Sandra could begin to address the
power issues and the sex-role issues in Sandra’s marital discord and
to challenge Sandra’s irrational thinking (like her numerous
“should” statements). He asks what cognitions lie behind Sandra’s
beliefs about a woman’s role in marriage. Tania begins, “Well, she
talked about this sermon she heard that really struck home.”
“Ah, religion!” interrupts Dr Schwartz. “I remember well
something brilliant Albert Ellis wrote a few years ago: The fairly
obvious fact’ Ellis said, is ‘that what we usually call neurosis,
nervous breakdown, mental illness, or some other term denoting
serious emotional malfunctioning is really a subtle designation for
religiosity’ ” (Ellis 1978:10).
Tania, for whom spirituality is important, but who is
uncomfortable both with her supervisor’s clear rejection of religion
and with the enthusiasm of Sandra’s black Pentecostal Christian
tradition, is unsure how to respond. She recalls, however, that
Sandra has stressed that “Honor your father and mother” was the
Scriptural passage behind her sense of obligation to her father. And
Sandra had mentioned with enthusiasm the strong, independent
women in her church. Plus the clear message from the pulpit
(delivered by preachers of both genders) that males and females are
equally responsible to “strive for holiness” and that “the Word of
the Lord comes to all who are ready to hear it.”
Tania also knows that the marital tension stems in part from
José’s rejection of all religion and spirituality, including the Catholic
religion of his youth. She knows he has formulated his beliefs about
the submission of women from his own scattered readings in
conservative political philosophy and sociobiology. “It’s a fact of
nature,” he has told Sandra, “that the male partner is the superior of
the female. Just look at the animal kingdom.”
Supervision following the sixth therapy session is interrupted by
a telephone call. The case representative from Sandra’s managed
care provider has finally returned Dr Schwartz’s call, six days after
Sandra and Tania had received a letter stating that only two more
sessions had been authorized for Sandra, for a total of eight sessions.
Using the wellhoned confrontive skills he developed in his RET
training, Dr Schwartz launches an attack on the irrationality of the
session limit. He argues for the rights of clients to receive health
52 ETHICAL THEORIES IN PSYCHOTHERAPY
care (including mental health care), Tania’s assessment and therapy
skills, and, most importantly, the benefits of therapy for Sandra.
When Dr Schwartz pauses to catch his breath, the representative
jumps into the conversation and wearily reads from a script,
“Consistent with its belief in scientifically based clinical care, and
with its contract with your client’s self-insured employer, Health
Options Systems Services has established a panel of leading clinical
psychological science experts. They have reviewed available
research evidence and determined appropriate treatments and
session limits for various diagnostic groupings. We reimburse only
therapy that treats serious psychological problems (not elective
therapy for personal growth) and only empirically supported
treatments. The panel’s guidelines indicate that clients with Specific
Phobias need only eight sessions of cognitive-behavioral therapy.
And Sandra will soon reach that limit. Now, on the forms you
submitted you diagnosed Sandra as having a Specific Phobia. That’s
correct, isn’t it, Dr Schwartz?”
“What health options does Sandra have, then?” asks Dr Schwartz,
with uncharacteristic meekness.
Sandra, Tania, and Dr Schwartz decide to pursue Sandra’s only
available option: appeal the eight-session reimbursement limit to
the Health Options Oversight Panel (HOOP). They fill out the sixpage HOOP form and submit it. They assert that the elimination of
Sandra’s irrational thinking and its replacement with more rational
thinking should be the goal of therapy, a task “elegant” RationalEmotive Therapy (RET) (Ellis and Bernard 1985) should be able to
accomplish by the end of Tania’s internship year, within fifty
sessions. When asked to explain why this goal should be pursued,
they write, “Rationality. Sandra’s right to mental health care and
her right to choose her own treatment and treatment goals should
be preserved. Furthermore, extended therapy would substantially
benefit her mental health and, possibly, her physical health, as
ample research has indicated.”
After three weeks, HOOP responds to the appeal with a succinct,
“Appeal denied.”
Sandra takes the rejection in her stride, stating, “Well, I’ll be okay.
I haven’t been very nervous at work lately anyway. I’ll just pray
more. And bring all this up in my Bible study. And don’t you worry
about that ninth session. You couldn’t have known they wouldn’t
pay. I’m an honest person and I believe in paying my bills.”
Tania seriously considers a career change.
And Dr Schwartz has an interesting conversation with his
stockbroker about his retirement stock portfolio. portfolio. “I’ve got
a great tip for you, Dr Schwartz,” she says. “Buy stock in Health
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 53
Options. Their earnings are way up. What’s more, they just landed
new contracts with two Fortune 500 corporations! Let me tell you, Dr
Schwartz, I think the future of that stock is very bright!”
A variety of theoretical ethical issues may be seen in this case. Part of the
complexity of this case, and of understanding those issues, stems from
the fact that the interests and ethical convictions of numerous parties are
at stake. To address the ethical nature of this therapeutic relationship, we
need to consider not only the values and ethical theories of Sandra and
Tania, but also those of others with an interest in this therapeutic
relationship. Those stakeholders include: Sandra’s husband, José;
Sandra’s father; Sandra’s employer (because its productivity may be
enhanced by employees who are “well-adjusted” or mentally healthy;
however, because the company is self-insured, large therapy expenses
would hurt the company and its employees); the client corporation for
whom Sandra speaks (if she remains in therapy and becomes more selfconfident and assertive, she may decide to reveal to the public the
corporation’s illegal dumping of toxic wastes); Dr Schwartz; Tania’s
training program (which, due to its training philosophy, wants its
students to have long-term clients); the internship site; Health Options
Systems Services (HOSS); the HOSS panel of clinical psychological
science experts; and the HOSS stockholders. Each party has a stake in
how therapy is conducted; each has ethical convictions relevant to
Sandra’s therapy; varying approaches to Sandra’s therapy will have
differing consequences for each. The psychotherapy office has become
(has always been?) very crowded indeed.
Is it meaningful to talk about goodness, virtue, and
moral obligation?
Can we legitimately assert that a particular behavior is right, a particular
end or goal for therapy good, or a particular characteristic of a person
virtuous? Is it valid to claim that Sandra’s desire to look after her father is
right? that her becoming more rational would be a good therapy
outcome? that Tania’s warmth and compassion are virtuous?
Some ethical theorists think it legitimate to answer those questions;
others think not.
In their ethical theory, logical positivists asserted that it is cognitively
meaningless to answer ethical questions. They claimed we can make only
two kinds of meaningful assertions: analytic (e.g. those of logic and
mathematics) and empirical (originally defined narrowly as assertions
verified by observation) (Toulmin and Leary 1992). Ethics, metaphysics,
and theology were accordingly dismissed as cognitively meaningless
(O’Donohue 1989; Pojman 1995b; H.Putnam 1993). Emotivism, notes
54 ETHICAL THEORIES IN PSYCHOTHERAPY
Koch, “was the more or less official view of logical positivism” (Koch
1969:140). Emotivists hold that ethical assertions are, in fact, nothing but
expressions of emotion. And so A.J.Ayer “held that the moral judgment
that murder is wrong reduces to the emotional expression ‘Murder—
Boo!’” (Pojman 1995b: 270). Ayer would thus assert that “It is good that
Sandra cares for her father” really means “Hurrah for Sandra!” and
nothing more.
Because logical positivism has influenced psychology so profoundly
and pervasively (Leahey 1997), some psychotherapists assume the truth
of its ethical theory. But others think it both justifiable and meaningful to
make ethical assertions. And so some who accept logical positivism as a
philosophy of science but reject it as an ethical theory, along with some
who take seriously the intellectual challenges to logical positivism that
have led most philosophers to reject it (Suppe 1977), think it both
justifiable and meaningful to make ethical assertions like, “It is good for
Sandra to be free of crippling fears” or “Corporations ought not to dump
toxic wastes illegally in order to maximize profits.”
In contrast to logical positivism, relativism permits us to make some
meaningful ethical claims, albeit claims that are quite limited in scope.
Although different types of relativism have been distinguished (Wong
1991), Pojman defines relativism as the view “that there are no
universally valid moral principles, but rather that all moral principles are
valid relative to culture or individual choice” (Pojman 1995b:26). That is,
the truth of a moral claim is relative to a particular culture or person. A
relativist might thus assert that the moral assertion, “It is good for
persons to be autonomous,” is true in Western cultures, but not in other
cultures. Or might state, “Because of the values my wife and I share, it
would be wrong for me to impose my values on her. But it would be
right for José to impose his values on his wife because doing so is
consistent with the moral view he and Sandra have chosen. Feminist
ethics are true for me, but not for José and Sandra.”
The polar opposite of relativism, ethical absolutism, holds that “there is
only one correct answer to every moral problem.” Regardless of person
or culture, “absolute principles…provide an answer for every possible
situation in life” (Pojman 1995b:268). “Authoritarianism” and
“dogmatism” are terms often used to characterize this view.
Relativism has produced devoted champions and equally devoted
foes, with advocates often producing vivid examples that support their
positions. Relativists point to particularly egregious examples of cultural
hegemony, like missionaries who declared immoral the nakedness of
natives. And so they would point to the absurdity of Sandra’s claim she is
obligated to prevent her father’s neighbors from thinking she is neglecting
her father (absurd unless she chose that obligation or it was a cultural
belief). Absolutists, on the other hand, might point to the Holocaust,
asserting that—whatever Nazi Germany or any other culture might hold
—the annihilation of millions of Jews was wrong. According to
absolutists, the failure of relativists to acknowledge the immorality of
genocide and other moral absolutes (like the necessity of honoring one’s
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 55
parents) has led, and will lead, to horrendous consequences. To avoid that
dire fate, we need to adopt absolutism.
Some psychotherapists succumb to the temptation to engage in such
either-or thinking about the meaningfulness of moral discourse, reducing
the ethical alternatives to either relativism or absolutism. For
example, Richardson made the following observation about two
psychologists who write about morality:
Gergen and Shotter seem to engage in an extended form of what
Foucault called “Enlightenment blackmail,” insisting that we either
must endorse their counter-Enlightenment constructionism and
what Gergen calls the “morality of relativism,” or stand convicted
of an Enlightenment absolutism that tends to breed domination and
intolerance.
(Richardson 1995:317–18)
But Richardson immediately adds, “There just may be a middle ground.”
And, indeed, many who have wrestled with the ethical dimensions of
psychotherapy—psychologists, other psychotherapists, philosophers, and
others—hold some kind of middle ground.
It is far easier, however, to say that one holds a position “in the
middle” than to clearly describe that middle ground, to specify which
particular region within that middle ground is best, or to explain why we
believe that position is best. Indeed, I think the precise nature of the
optimal middle ground between relativism and absolutism is one of the
most crucial, and interesting, issues faced by those striving to understand
the ethical character of psychotherapy.
Psychotherapists have adopted a variety of approaches to that “middle
ground.” Some advocate an extensive set of ethical convictions; others
argue for a more limited set. Discriminations between issues considered
ethical and non-ethical are made in different ways. Consider, for
instance, Sandra’s desire (a) to be a good wife (to be virtuous) and (b) to
have a beautiful kitchen. Some would consider neither to be an ethical
issue because no obligations or rights are involved; others would
consider both to be ethical issues, because both involve some sort of
ideals; still others would consider her desire to be virtuous “ethical,” but
not her aesthetic desire to have a beautiful kitchen.
When making ethical judgments, some advocates of a middle ground
focus on abstract universal principles and give little weight to the
context, culture, and personal convictions of participants; others take
those contextual factors very seriously. (This they see as the grain of truth
in relativism: making wise ethical decisions about moral matters requires
close attention to relevant contextual factors, that is, requires making
judgments “relative” to context and culture.) The latter group would
consider Sandra’s religion and ethnicity, and the culture and contexts of
the other stakeholders in her therapy, to be very important in an ethical
56 ETHICAL THEORIES IN PSYCHOTHERAPY
analysis of her therapy, although they would not assume that those
contextual factors fully determine the ethical conclusions that should be
drawn.
Finally, many who hold a “middle ground” ethical position argue for
an attitude on the part of the psychotherapist that is “ironic and selfcritical” (L.A.Sass 1988:263) and humble. Rejecting relativism, Richardson
and Woolfolk note, “we can make valid interpretations and come to valid
substantive ethical insights, even if they are never final or certain”
(Richardson and Woolfolk 1994:222). And, rejecting absolutism,
Prilleltensky argues that there is “a big difference between searching for
the best moral option under a particular set of circumstances and the
pursuit of a dogmatic set of rules” (Prilleltensky 1997:518).
Some postmodernists occupy a middle ground between relativism and
absolutism (e.g. Bauman 1993, 1995). Other postmodernists are ethical
skeptics or relativists. As Prilleltensky (1997) and Rosenau (1992) note, two
orientations, the skeptical and the affirmative, characterize
postmodernism’s rejection of modernism’s hopes for reason and the self
(whether the self is viewed as the detached, objective observer or the selfaware, subjective experiencer—Taylor 1989). The skeptical postmodern
orientation (ironically) resembles the ethical theory of logical positivists
in its refusal to take any moral stands. By way of contrast, affirmative
postmodernists use the methods of deconstruction, but do so to further
moral aims. Their approach, Rosenau notes, is “nondogmatic, tentative,
and nonideological.” But, she continues, “many affirmatives argue that
certain value choices are superior to others” (Rosenau 1992:16).
Unfortunately, no single term satisfactorily captures the full range of
views held by those in this “middle ground.” This dispute about
terminology reflects deep underlying philosophical differences. For
example, to describe the “middle ground,” Pojman uses the label “ethical
objectivism,” which he defines as “the view that moral principles have
objective validity whether or not people recognize them as such” (Pojman
1995b: 272). But some who reject both relativism and absolutism argue
for subjectively valid ethical principles. Carl Rogers (1961), for instance,
stated that:
the good life, from the point of view of my experience, is the process
of movement in a direction which the human organism selects when
it is inwardly free to move in any direction, and the general
qualities of this selected direction appear to have a certain
universality.
(Rogers 1961:187)
Still others (e.g. Richardson and Woolfolk 1994; L.Sass 1988) are drawing
upon, and developing, very sophisticated hermeneutic approaches that
avoid what they consider to be a problematic subject—object (or
subjective—objective) dichotomy.
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 57
I will use the imperfect term “moral realism” (Brink 1989; R.W.Miller
1991; Shweder 1990) to refer to the middle ground between relativism
and absolutism. By that term, I mean positions which hold that ethical
convictions can refer to something real, to something that is not artificial,
not imaginary, not fully constructed by participants in moral discourse,
which hold that “moral facts and true moral propositions” (Brink 1989:
14) exist. I deliberately don’t specify what “real” means, as I intend
“moral realism” to be a rubric embracing a variety of metaphysical,
epistemological, and axiological convictions that share in common only a
rejection of skepticism, relativism, and absolutism. But all moral realists
would hold, for instance, that the wrongness of rape is a real, or genuine,
wrongness, whatever any particular individual may choose to believe, or
any culture holds.
I will touch below upon the nature of some of those underlying
disputes about the nature of the “middle ground” of ethical realism,
because those disputes stem from differing answers to questions about the
basis of goodness and moral obligation, about ethical principles, and
about ethical knowledge. I should note, however, that those holding the
logical positivist ethical theory may find the following sections to be of
little personal benefit, because they believe there is no cognitively
meaningful answer to ethical questions. Since the discussion of ethical
principles and knowledge in later sections in this chapter assumes that
some behaviors are right or good and some persons virtuous, emotivists
and relativists would find the remainder of this chapter of interest only
as a way to increase their awareness of other ethical positions, lest a
failure to do so should result in imposing their ethical theory on clients or
failing to work within the framework of a client’s ethical theory.
The basis of goodness and moral obligation
How can we justify a claim that it would be good for Sandra to be free
from anxiety and depression? that it is wrong for the company Sandra
represents to illegally dump toxic wastes? that Tania and Dr Schwartz
were right to appeal HOSS’s refusal to pay for more than eight sessions of
Sandra’s therapy? that it was virtuous for Tania to be warm, empathic,
and congruent?
Answers to those ethical questions cannot be justified in the manner
scientific assertions are justified (see Chapter 6). So how can they be
justified? On what basis can we make ethical assertions?
Before we examine four general types of justifications for ethical
assertions, two basic distinctions must be made—between aretaic and
deontic ethics (or between an ethics of character and an ethics of duty)
and between moral and nonmoral judgments (discussed briefly in
Chapter 2). These distinctions are important in part because they clarify
the breadth of the ethical issues for which justification is necessary.
An aretaic judgment (from the Greek arête, meaning excellence or
virtue), or an ethics of character, has to do with ethical judgments about
58 ETHICAL THEORIES IN PSYCHOTHERAPY
“persons, motives, intentions, traits of character, and the like, and we say
of them that they are morally good, bad, virtuous, vicious, responsible,
blameworthy, saintly, despicable, and so on” (Frankena 1973:9). For
example, a person characterized by the good end of honesty (a person
whose character is honest) would be considered worthy of praise.
Therapists making aretaic judgments may assert that a person is “healthy,”
“rational,” or “a good therapist.”
A rough parallel can be drawn between aretaic assertions about virtues
and the idea of a trait in psychology: both refer to relatively enduring or
consistent characteristics of persons. What distinguishes a moral trait, or
“virtue,” from a general trait is that a normative judgment is made about
that consistency: it is regarded as praiseworthy or blameworthy, good or
bad.
By way of contrast, a deontic judgment (from the Greek deon, which
means duty), or an ethics of duty, has to do with a person’s actions, not with
his or her character or traits. According to Frankena, when we make a
deontic judgment, “we say that a certain action or kind of action is
morally right, wrong, obligatory, a duty, or ought or ought not to be
done” (Frankena 1973:9). For instance, we may assert that it would be
wrong for Tania and Dr Schwartz to defraud Health Options or wrong
for José to demand that Sandra be submissive. Or we may argue that it is
right for Tania to maintain confidentiality in therapy.
Frankena distinguishes between aretaic and deontic judgments, but
suggests they are actually “complementary aspects of the same morality”
(Frankena 1973:65; see Meara et al. 1996). So, if Tania asserts that Sandra
has become healthy or rational (that is, possesses the virtues of health or
rationality), her aretaic judgment implies deontic judgments about
particular acts: Sandra’s behaviors are, in the main, healthy or rational.
The reverse is also true: evaluating specific behaviors sometimes implies
an overall evaluation of the person. If Sandra’s behaviors were
consistently judged to be healthy or mature, we might consider her a
healthy or rational person.
Although the primary reason for introducing the aretaic-deontic
distinction in this context is to make clear the breadth of ethical concepts
for which justification is needed, the distinction has practical advantages:
careful thinking about virtue and obligation can help clients make such
judgments more appropriately (“appropriately,” of course, entails an
ethical judgment about what is appropriate). Therapists can support
deontic assertions—for example, “Clients such as Sandra should honor
their financial obligations to therapists when having the financial
resources to do so (and perhaps even when not)”—but can challenge
clients’ overly-quick jumps to aretaic judgments (e.g. “I’m ‘Tm such an
awful person!” “Why?” “Because I shouldn’t have spent $100 gambling in
Atlantic City. I should have paid my bill to you instead”). In addition,
judgments about a client’s character can sometimes not only be
warranted, but important to therapy. A recidivist incest offender may
need to have some sense of himself or herself as flawed, blameworthy, or
in need of help—so he or she will not claim that a particular incestuous
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 59
act was “just a slip. Yes, I did something wrong. But I’m okay now.” For
such a person to refrain from any self-evaluation would be problematic,
as would making either an entirely positive or an entirely negative selfevaluation.
A second distinction—between moral and nonmoral judgments—is
also important. As discussed in Chapter 2, moral refers here to a
particular kind of judgment, whose opposite is nonmoral rather than
immoral. According to Frankena, whose views on this point are not
universally accepted, moral judgments have to do with:
rules, principles, or ideals…that pronounce actions and agents to be
right, wrong, good, bad, etc., simply because of the effect they have
on the feelings, interests, ideals, etc. of other persons or centers of
sentient experience, actual or hypothetical…. On this conception, a
morality must embody some kind of social concern or consideration.
(Frankena 1976:125–6)
To use an example unrelated to therapy, in playing baseball, one could
assert that when there are two outs, loaded bases, and a full count, a base
runner ought to run on any pitch. However, we would not label as
immoral a player’s failure to run. Stupid, perhaps, but not immoral. This
is because whether or not to run is a nonmoral issue. On the other hand,
if a base runner failed to run because he or she had accepted a bribe to
throw the game, we might properly term that act immoral—because
cheating is a moral issue.
Sandra’s psychotherapy raises several moral issues. Is it wrong for
corporations to illegally dump toxic wastes? Are third-party payers
obligated to pay for therapy whenever doing so would benefit clients? Do
people have a right to therapy? Was it right to file an appeal of HOSS’s
decision to pay for more than eight sessions of therapy? Was it wrong for
HOOP to deny the appeal? Nonmoral normative issues are present as
well. Is it good that Sandra has a beautiful kitchen? Would her reduced
depression and anxiety be a good outcome? Is Tania’s goal that Sandra
develop greater emotional self-awareness a good therapeutic goal? Is Dr
Schwartz’s goal that Sandra adopt an elegant RET philosophy a better
(“more good”) therapeutic goal?
I think the justification of nonmoral values is particularly important,
because I believe that mental health values, which when broadly defined
are the most important values involved in psychotherapy, are generally
nonmoral values, though usually intermingled with moral issues to some
extent. Justifying nonmoral values involves asking questions like these:
on what basis does Dr Schwartz claim that rationality is the best possible
way for Sandra to function? do Rogerians claim that the fully functioning
person is to be preferred to a person whose life is directed by externally
imposed conditions of worth? do we claim that mental health is to be
preferred to mental illness?
60 ETHICAL THEORIES IN PSYCHOTHERAPY
In clinical practice, however, the neat moral-nonmoral distinction often
breaks down. Therapists cannot always address nonmoral values
without also addressing moral values, as when moral and nonmoral
values conflict. For example, one source of Sandra’s tension is balancing
her perceived nonmoral aspiration to have a beautiful kitchen with her
perceived moral obligation to her father. And a therapist who tries to
avoid moral issues by focusing solely on the nonmoral goal of Sandra’s
happiness would be privileging nonmoral considerations over moral.
Sandra’s dilemma has arisen in part because she is trying to balance her
happiness against what she sees as an obligation, an ideal, or both, to be a
good wife and a good daughter. Therapists who believe that Sandra’s
happiness is all that matters have adopted an ethical theory in conflict
with Sandra’s more complex theory, which combines an allegiance to
nonmoral values (like happiness) with an allegiance to moral values.
Furthermore, because those therapists would be trying to replace her
moral values with nonmoral values, they would have entered the moral
realm.
And so whatever ethical stance one takes concerning Sandra’s situation,
both moral and nonmoral issues become involved. And so moral and
nonmoral ethical assertions alike need justification. A broad array of
justifications for ethical assertions has been proposed. It is to a
consideration of four types of justification that I now turn.
Social contract
Some argue that moral standards are based on agreements about how
societies are to function. For instance, Tania should maintain
confidentiality concerning Sandra’s therapy because society has agreed
therapists will do so. What is critical is that consensus has been reached,
not the specifics of the consensus. Ethical judgments are justified by
reference to such agreements. So, for instance, if the legitimacy, indeed,
the goodness, of psychotherapists is challenged, therapists need only
point to legislation establishing licensure.
Critics of this position would argue that the mere presence of an
agreement does not provide a convincing basis for ethical assertions:
people have entered into less than optimal, indeed, bad, wrong, and even
evil, agreements. Mere consensus is not enough; convincing reasons for it
must be set forth.
But even if unsatisfactory as a full-fledged justification for ethical
assertions, a social contract can serve the very important function of
articulating agreement among those with deep ethical differences. One
need not have consensus on the level of ethical theory to agree, for
instance, that the licensure of mental health professionals benefits
society. Likewise, there can be—and, indeed, I think there is—a social
contract among therapists and society that a certain core of consensual
values will be present in therapy and that ideas falling outside of that
consensus will not ordinarily be part of therapy. Although a social
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 61
contract approach to justifying ethical convictions does not address the
deepest level of justification, as I will argue in Chapter 10, the idea of
social contract relevant to psychotherapy is vitally important. It can be an
important part of a social philosophy regarding psychotherapy, and can
contribute to public policy pertaining to psychotherapy.
Tradition
Some claim that morality is fundamentally about tradition or custom.
Anthropologist Ruth Benedict, for example, believed that morality “is a
convenient term for socially approved habits” and “the good” is “that
which society has approved” (Benedict 1934:73). What has always been
believed to be good, right, and virtuous is the basis for making ethical
judgments. In that formulation, of course, an appeal to tradition is
relativistic because ethics becomes relative to the culture to which a
tradition belongs. In part because of opposition to that relativism, most
moral philosophers (e.g. Frankena 1973) join with many psychotherapists
in rejecting tradition as a basis for making ethical assertions. It is, of
course, possible to consult and draw upon a tradition without blindly
accepting it. We can, for instance, read critically from the Freudian,
Rogerian, or Skinnerian traditions as part of an attempt to determine an
optimal ethical course in therapy.
In an important sense, tradition (or communities of discourse) forms
the basis of all ethical thinking. MacIntyre (1966, 1984), for example,
argues that tradition shapes what and how we perceive morally, how we
define moral terms, how we talk about ethical issues, and how we resolve
ethical dilemmas. Furthermore, Taylor (1989) argues that the modern
identity rests upon a variety of ethical traditions about “the good,” in
relationship to which we define ourselves. Whenever we speak about the
self, then, we draw upon these multi-layered ethical traditions about the
self. And Kirschner (1996) documents how psychoanalysis, although
intending to be anti-religious and scientific, in fact drew upon themes
from the religious and Romantic traditions in its morally-loaded account
of the goals of human life.
These commentators thus argue that we are profoundly shaped by the
communities and traditions of which we are a part, that we are inescapably
shaped in complex, multi-faceted ways of which we are but part aware—
because it is hard for us to see (and understand) a tradition when that
tradition shapes how we see (and understand) ourselves and the world.
And yet we ignore culture and tradition at our peril. And so we need to
examine tradition critically, employing some sort of criteria in doing so.
But the fact we base our ethical views in part on tradition is unavoidable.
And too often neglected.
62 ETHICAL THEORIES IN PSYCHOTHERAPY
Definism
Definists argue that ethical judgments are “rooted in the nature of things”
(Frankena 1973:99), that is, are rooted in a particular definition of “the
nature of things.” What ought to be and what is good are based on what
is. The challenge facing advocates of this view is to establish and properly
define “the nature of things.”
A variety of definitions of “the nature of things” has been employed in
justifications of ethical assertions. In this section, I will discuss in turn
“nature,” other metaphysical understandings of reality, and the self as
bases for ethics.
According to ethical naturalists, nature itself is the basis for ethics.
Employing a wide range of understandings of “nature,” they would all
argue that Sandra’s desire to care for her father arises, in some way, from
nature.
Campbell’s (1975) evolutionary ethics, which employs a strictly
materialistic metaphysical understanding of nature, emphasized survival
as the good toward which evolution aims. In explaining Sandra’s desire
to care for her father, naturalistic ethicists might argue that her desire to
care stems from the survival value to the species associated with such
care. Skinner also held such a naturalistic view (Vogeltanz and Plaud
1992), as do Schwartz and Bilsky in their research efforts to establish the
“universal psychological structure of human values” (Schwartz and
Bilsky 1990:878). And Wallach and Wallach (1990) argued for another
form of naturalistic ethics, asserting that human motivation provides a
basis for an ethics concerned for the common good.
In the example given above, José held a variation of this view in
asserting that the animal kingdom (“nature”) teaches us that “the man”
should dominate “the woman.” Although most psychotherapists would
reject José's views, his vulgar ethical naturalism should be carefully
distinguished from more sophisticated versions of naturalistic ethics (e.g.
Brink 1989; Flanagan 1996; Rottschaefer and Martinsen 1990; Ruse 1986;
Wright 1994).
Although appealing to many, naturalistic ethics has been subject to
ample criticism as well (e.g. Gewirth 1986; P.E.Johnson 1995; Kitcher 1985),
including criticism from scientists who reject the claim that naturalistic
ethics is “the” scientific approach to ethics, and from feminists concerned
that the deeply conservative conclusions drawn by some naturalistic
ethicists enshrine in “nature” social arrangements that are deeply
damaging to women and that are, in substantial measure, cultural, not
biological. In her discussion of the reasons for the development of
feminist bioethics, for instance, Sherwin noted that “many moral theorists
believed that subordination was the natural condition of women”
(Sherwin 1992: 43–4).
Humanistic psychologists hold another form of naturalistic ethics, with
nature as the basis of human goodness (DeCarvalho 1989, 1991). Rogers,
for instance, claimed that “both personal and social values emerge as
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 63
natural, and experienced, when the individual is close to his [or her] own
organismic valuing process.” If we are in touch with the (natural)
organismic valuing process, it “will prove to be an organized, adaptive,
and social approach to the perplexing value issues which face all of us,”
and will make for the “survival and evolution of {the human} species”
(Rogers 1964:167, 160). Browning points to the implicit ethical theory
upon which humanistic psychologists rely: harmony will result when
each person strives to fulfill his or her own potential. Drawing upon a
Romantic view of “the nature of things,” some humanistic psychologists
believe that individual desires and feelings, when not corrupted by
society, will harmoniously blend with those of others so everyone’s needs
will be met. Rogers’ basic assumptions about “nature,” the assumptions
giving rise to his ethical assertions about “fully functioning persons,” are
thus quite different from those held by other naturalistic ethicists.
Another form of “naturalistic ethics,” one that draws upon still another
understanding of “nature,” can be found in some forms of Roman
Catholic ethics, especially those derived from Aquinas (Edel 1991). To
oversimplify, some Catholic moral theologians assert that the nature of
human sexuality, properly understood, has to do with procreation in the
context of heterosexual marriage. Sexual relations that are not between
husband and wife for the express purpose of procreation are accordingly
viewed as unnatural, and hence immoral. Birth control, homosexuality,
masturbation, and abortion are all viewed as wrong, in part because they
are unnatural. That concept of nature thus produces an ethical stance
substantially different from that resulting from materialistic
understandings of nature. Indeed, Flanagan’s (1996) metaphysical
position explicitly rules out any “transcendent” considerations in his
naturalism, whereas the Catholic position assumes that God is
inextricably linked to nature, as its creator and sustainer. Hence, simply
invoking “Nature” does not resolve ethical questions. People also need to
explicate and justify their understanding of nature.
Other attempts to ground ethics “in the nature of things” rest on other
metaphysical foundations. Plato and Aristotle, for instance, intertwined
metaphysics, epistemology, and ethics in ways foreign to much modern
(and postmodern) thinking. And some religious thinkers rely upon
metaphysical assertions, such as the existence of God, to ground ethics.
Marty (1983), for instance, argues that human health and well-being are
gifts from God (while also arguing that reason and careful empirical
investigations offer important clues to help answer ethical questions).
Those holding other religious traditions have different assumptions
about “the nature of things.” I spent one New Year’s Day, for instance,
with a Japanese woman who prayed to a rock god. She believed that that
god (the rock) was the basis for her duty to pray to it. When I, an
insensitive 21-year-old, asked her if she really believed that rock was a
god, she slowly responded, “I am Japanese.” In retrospect, my judgment
at the time should have been seasoned with the kind of caution I earlier
urged for critics of José’s vulgar evolutionary ethics. Psychotherapists
likewise need to distinguish between simplistic (and sometimes
64 ETHICAL THEORIES IN PSYCHOTHERAPY
irresponsible) forms of a position and sophisticated and responsible
forms of that same position. With regard to theological bases for ethics,
for example, some philosophers (e.g. Adams 1987; Quinn 1978) have
recently developed philosophical bases for Christian ethics that address
many of the previous criticisms of such positions.
Finally, some argue that ethical assertions find their basis in the self.
Those who hold this view differ significantly, however, because they hold
different beliefs about the self (see Taylor 1989). Existentialists argue that
individual choice makes a particular act or decision right or wrong, good
or bad. The fact that a person makes an authentic choice is crucial, not
any intrinsic characteristics of the act or decision itself. As Guignon
notes, Medard Boss believed that, “once genuine freedom is achieved,
‘mankind’s ethics becomes self-evident’ and we will be able to ‘define
man’s basic morality’” (Guignon 1993:222). So, we choose goodness, we
choose health. Goodness and health cannot be “done” to us, chosen for us,
or given to us. They do not exist prior to our choices, like something
awaiting discovery. They come into existence as we choose them, and not
before. Goodness and rightness, accordingly, are radically individual and
unique. Heidegger and others have also stressed—in ways that differ
from existentialists—that human beings are “self-constituting” (Guignon
1993:223).
The self is central to ethical judgment in a second way in Aristotelian
ethics (MacIntyre 1984; Sherman 1989). Virtuous persons can see what is
good and bad, right or wrong, in ways those who are not virtuous cannot.
Ethical judgments are based on, or grow out of, a person’s virtue or
character. In addition, Aristotle had clear beliefs about the nature of the
human beings, the selves, whose virtue or character permitted clear
ethical vision. For Aristotle, rationality was the highest end for a human
being, so the rational person was happiest, and most moral. Again,
metaphysical assertions about human nature underlie definist ethical
positions that find a basis for ethics in the self.
Some who focus on the self contend that goodness and virtue arise out
of selves who actualize their potentials. Maslow’s self-actualized persons
were described by him as “strongly ethical” and capable of “greater love”
(Maslow 1956:183, 182). His claim was that within each individual lie
dormant characteristics (some moral, some nonmoral, and some not
ethical at all) awaiting expression. This claim entails metaphysical
assumptions, as ideas about self-actualization rest on the metaphysical
belief (or “romantic faith”—Guignon 1993:222) that individual potentials
will harmoniously blend so the needs of all people will be met.
And so a wide variety of perspectives is held by definists, though all
base their ethical convictions on “the nature of things.” In addition to the
metaphysical task of clarifying and justifying their position on the
“nature of things,” definists must also address the so-called is-ought, or
fact-value, problem. As noted earlier, it was long widely held that we
cannot draw ethical (“value” or “ought”) conclusions from descriptive
(“fact” or “is”) premises. Engelhardt and Wildes argue that “human
nature is a biological fact, which must be placed within a moral vision in
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 65
order to derive moral consequences from it” (Engelhardt and Wildes
1994:142). “The nature of reality” must thus be understood in moral
terms. Similarly, Holmes (1984) notes that one cannot move from the
premise of a particular “is” to an “ought” without the “ought” already
being contained in the “is” of the premise.
Non-naturalism or intuitionism
Some argue that the questions, “How we are to justify ethical beliefs?”
and “What reasons should we give?” are poorly formulated. Ethical
judgments are self-justifying, not being the type of judgment that we can
justify through reason or nature. Someone may claim to know that this is
the case by claiming that ethical judgments are intuitively obvious, or
clearly and distinctly true (Frankena 1973). We need go no further than
our sense of what is moral. Sandra’s sense of obligation to her father can
be understood to be intuitively obvious. She needs to balance her
conflicting, intuitively justifiable moral leanings. Meehl adopts a
sophisticated version of this position, arguing that we adjust our ethical
ideas in response to persons he labels ERDERVE-qualified, that is, those
who have “Extended Rational Discussion [based on] Extensive Real [and]
Vicarious Experience” (Meehl 1981:7). The most serious challenge which
advocates of this position must address is the lack of agreement about the
intuitions on which ethics is supposed to be based.
Virtues and principles
What principles should we use to decide what is good, right, or virtuous?
What principles would it be best for Sandra to use when she makes
ethical decisions? What principles should Tania use? What kind of person
should Tania be? If the therapeutic relationship is optimal, what kind of
person will Sandra be when therapy is at an end?
These are questions addressed by the area of ethical theory known as
normative ethics (Frankena 1973). Less abstract than the two areas of
theoretical ethics just discussed and often more immediately helpful in
addressing a concrete ethical question, two general approaches have
traditionally been used: teleological (or consequentialist) and
deontological (Pojman 1995b). They focus, respectively, on the
consequences of actions (e.g. “Will this behavior bring about the good
end of better mental health for Sandra?”) and on basic ethical obligations
(e.g. “Will this action respect Sandra’s autonomy?”).
Virtues
Although teleological and deontological approaches have dominated
discussions of ethics in the twentiethth century, in the last two decades
66 ETHICAL THEORIES IN PSYCHOTHERAPY
virtue ethicists have strongly challenged their dominance. Virtue ethicists
ask questions like these: what kind of person is Sandra? what is her
character? what personal characteristics or virtues ought to present in the
professional psychotherapist qua professional? what character ideals
would it be best for Sandra and Tania to develop?
Meara, Schmidt, and Day (1996) distinguish between “principle ethics”
and virtue ethics, although regarding them as complementary. To praise
Tania for being a just woman (for exhibiting that virtue), for example, is
complementary to asserting that she should act justly (in accord with the
deontological principle of justice) with her clients.
However, virtue ethics emphasizes dimensions of ethics that principle
ethics does not. Virtue ethics addresses the emotions and motivations of
ethical agents, moral perception (the ability to see what is ethically
relevant in a particular situation), practical ethical reasoning ability
(prudence), and the personal characteristics of the self, including “the
whole of a (person’s) life” (Brody 1994:211; see Punzo 1996). When Dr
Schwartz says that Tania is “a good therapist,” for instance, he is
evaluating her as a person, making a judgment about her motivation,
integrity, ability to see what is in clients’ best interests, and consistent
willingness to benefit clients. By way of contrast, principle ethics is more
cognitively oriented and abstract (e.g. addressing which principles we
ought to employ in making ethical decisions) and more focused on
specific ethical decisions and behaviors.
Psychotherapists have recently argued that “good psychotherapists”
exhibit particular virtues. Doherty (1995) emphasizes three: caring,
courage, and prudence. Meara, Schmidt, and Day (1996) point to four:
prudence, integrity, respectfulness, and benevolence. And K.S.Kitchener
(1996b) argued that therapists should take seriously the feminist virtues of
caring (Noddings 1984) and trustworthiness (Baier 1993).
Teleological or consequentialist theories
These approaches assert that we can best answer ethical questions by
focusing on the telos (“end”) of an act, that is, on its consequences. The
basic ethical principle is maximizing positive consequences. More
specifically, according to Frankena, “teleological theory says that the
basic or ultimate criterion or standard of what is morally right, wrong,
obligatory, etc., is the nonmoral value that is brought into being”
(Frankena 1973:14). Different teleological theories focus on different
consequences, that is, on different ends or nonmoral goods (e.g. personal
happiness, a healthy family system, or the improvement of human
welfare in general). Should Sandra (and Tania) strive above all to
maximize the nonmoral good of freedom from psychological distress? the
nonmoral good of a satisfying marriage?
Traditional answers to those questions (which face everyone, including
the advocates of virtue ethics) include egoism (focusing on the best
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 67
interests of the self), altruism (focusing on the good of others), and
utilitarianism (focusing on maximizing the general good).
Egoism, not to be confused with egotism, holds that, in making ethical
decisions, one should consider what will further one’s own well-being.
Sandra needs to look out for herself, concerning herself with others only
to the extent that doing so will benefit herself.
Psychotherapists (Wallach and Wallach 1983) and psychologists
(Schwartz 1986) generally embrace egoism. Schwartz argues that this is
because they erroneously assume science requires it. Many psychologists
may believe that the only reason human beings perform actions
traditionally labeled “moral” is to receive some personal benefit, whether
decreased superego-generated anxiety in Freudian accounts, or receiving
reinforcement and avoiding punishment in behavioral accounts. Because
human beings inevitably act to further their own well-being
(psychological egoism), egoistic principles must therefore be used to
address ethical questions (ethical egoism). But Schwartz points out that
this jump from psychological egoism to ethical egoism is a non sequitur.
That human beings are customarily concerned about themselves does not
mean we should always try to maximize our own interests. Batson (1990)
has recently challenged psychological egoism on empirical grounds,
arguing that, in at least some instances, persons are motivated
altruistically, that is, are motivated to benefit others. Furthermore,
Wallach and Wallach (1983) have documented the harmful consequences
of egoism and outlined the advantages of alternatives to it.
I suspect that another reason egoism continues to be widely held is its
frequent pairing in a false dichotomy with altruism. Motivation is viewed
as being either egoistic or altruistic. Altruists, in one construal of the term,
hold that our decisions about what is good, right, and virtuous should
always be based on what will most benefit others, whatever the cost to
the actor. Because therapists are acutely aware of the harmful impact of
such “altruistic” motivation (e.g. the stress produced in Sandra by her
desire to give give sacrificially to to both father and husband) and
because therapists see that clients who claim to be altruistic are often, in
fact, motivated egoistically, therapists affirm ethical egoism.
To reduce ethical options to just the altruist and the egoist is
problematic, however. As anyone balancing commitments to self,
relationships, children, and career knows, most people balance concern
for the best interests of others with a concern for oneself. And this was, in
fact, Sandra Sandra’s situation. To reduce her choices to being selfish or
altruistic (being solely concerned about others) is to misunderstand the
nature of her dilemma.
Rejecting both egoism and the false egoism-altruism dichotomy,
Doherty (1995) and others have recently argued that psychotherapists’
overemphasis on the well-being of the individual needs to be replaced
with a balanced concern for the client(s), the well-being of family
members (especially children), and the well-being of the community.
By way of contrast, advocates of utilitarianism argue that, to make
ethical decisions, we need to determine what produces the most
68 ETHICAL THEORIES IN PSYCHOTHERAPY
goodness (or what produces the most utility, or usefulness, in reaching
that goodness). Frankena briefly summarizes this position: “the right is to
promote the general good” (Frankena 1973:34). Utilitarian elements are
often included in the statements of purpose of professional associations.
The American Psychological Association, for instance, states in its bylaws
that one of its purposes is “to advance psychology…as a means of
promoting human welfare” (APA 1994:1).
That statement alone, and utilitarian positions in general, offer Sandra
and Tania little concrete aid when they confront ethical issues in therapy,
however. The position must be fleshed out with much more specific
principles, principles delineating which actions will contribute to that
general good and which principles we should employ in thinking about
ethical issues in therapy. We need more specific guides to action, what
K.S. Kitchener (1984) called rules, when we confront specific ethical
situations.
And, indeed, some psychologists have adopted more carefully worked
out utilitarian positions. The goal of Wallach and Wallach’s (1990) ethical
approach, for instance, is to contribute to the common good. And when
Skinner, sociobiologists, and Cattell (Gorsuch 1984) emphasize the good
of the survival of the species, they are employing utilitarian ethical
theories.
Different consequentialist ethical positions thus emphasize the need to
consider the consequences of actions in Sandra’s life and therapy, but
disagree about the consequences considered most important.
Deontological theories
If teleological theories emphasize the consequences of actions in
determining what is good, right, and virtuous, deontological theorists
stress one or more principles that address whether an act is right. As
Pojman points out, “for the deontologist, there is something right about
truth-telling, even when it may cause pain or harm, and there is
something wrong about lying, even when it may produce good
consequences” (Pojman 1995b: 270). And so, if discriminating against
Sandra, and other minorities or women, best contributes to some general
good, a utilitarian would declare that discrimination right. A
deontological theorist, however, might use the principle of justice to
reject discrimination—whatever its consequences—because that action is
unjust.
Deontologists can employ one or more principles. Achieving
positive consequences can be one principle a deontologist uses in
deciding what is good, right, and virtuous. However, deontologists hold
that, in at least some situations (and for some deontologists, in all
situations), another principle or principles are needed: principles or rules,
such as those involving equality, freedom, harm-avoidance, justice, or
promise-keeping, should be used to decide what is right.
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 69
Biomedical ethicists generally employ deontological principles to
address ethical issues, perhaps the most influential formulation being
that of Beauchamp and Childress (1994; see Gillon 1994). Beauchamp and
Childress argue for four basic ethical principles: respect for autonomy,
nonmaleficence (avoiding harm), beneficence, and justice. Those
principles have been praised, vilified, and used extensively in bioethics
education, as well as being employed to understand professional ethical
issues in psychotherapy. To those four, K.S.Kitchener (1984) added a fifth
principle, “fidelity,” and Meara, Schmidt, and Day (1996) a sixth,
“veracity.” Applied to concrete situations, these principles are believed to
help therapists to understand their duties to clients and to conduct
psychotherapy in an optimally ethical manner. And, as Bersoff (1996)
notes, such principles are essential when psychologists (however
virtuous) address ethical dilemmas, especially those arising in novel or
conflictual situations.
Indeed, the greatest ethical dilemmas for clients and therapists occur
when ethical principles are in conflict. Sandra’s dilemma had to do with
balancing the principle of her own welfare, on the one hand, with her
perceived obligations to her husband and father, or her desire for a good
marriage and a good relationship with her father, on the other hand. Part
of the reason for Dr Schwartz’s uncharacteristic silence in response to the
Health Options’ case manager was the conflict between his commitment
to veracity (he believed Specific Phobia was the best diagnosis for
Sandra) and his commitments to beneficence (he and Tania were
obligated to act in Sandra’s best interests), to justice (he believed it wrong
to deny benefits to a client so clearly in need of therapy), to respect for
autonomy (Sandra’s choice to continue therapy should be honored), and
to fidelity (Tania should maintain a therapeutic relationship with Sandra
until therapy reaches its “natural” end). In addition, the Health Options’
case manager faced an ethical dilemma: Sandra’s well-being versus the
limited benefits provided by her employer, as clearly spelled out in the
explicit agreement into which Sandra (through her employment
agreement), the clinic at which she was being seen, and Health Options
had entered.
Dilemmas often arise because different stakeholders in therapy use
different principles: Dr Schwartz believed that psychotherapy should be
reimbursed until clients have adopted the “elegant RET” philosophical
position. Health Options’ administrators thought it would be wrong
(because a violation of the agreement between it and Sandra’s employer
and because extensive therapy is harmful to the best interests of US
business in a competitive global environment) to pay for fifty sessions of
therapy when Sandra’s only diagnosable problem, her fear of public
speaking, could be eliminated in eight. Still others would argue that it
would be wrong to “cure” Sandra in such a way that, after she returned
to work, she lied to the public without anxiety about her client
corporation’s illegal pollution. It would be wrong, they would argue, to
focus so exclusively on Sandra’s wellbeing that society as a whole was
harmed.
70 ETHICAL THEORIES IN PSYCHOTHERAPY
Some resolve such conflicts rigidly; others do so more flexibly. Some
use only one principle; others (e.g. Frankena 1973) produce mixed models
that combine deontological principles (like justice) with a consideration
of the general good. It may well be that therapists use ethical principles
like they use theories of psychotherapy: many are sloppy eclectics (using
whatever approach seems applicable, with no concern for consistency
across time or situation), some are nuanced eclectics (intuitively applying
different approaches depending on the circumstances, without being able
to easily articulate their reasons for doing so), and a few are systematic
eclectics (able to state clearly which approach they use in which situation
—and why).
In conclusion, clients and psychotherapists continually decide the best
course of action to take. This often involves decisions about what is good,
right, and virtuous, decisions based, in part, upon virtue, upon
teleological or deontological principles, or upon some combination of
those approaches. When a client employs a different ethical theory than
that used by his or her therapist, it is generally incumbent upon the
therapist to work, to the extent possible, within the client’s ethical
framework.
Ethical knowledge
A very difficult question of ethical theory remains: just how do we know
what is good, right, or virtuous? How can Sandra know that “it’s not right
for me to neglect my father when he is in need and I can help him”? How
can Tania know that Sandra should guide her life by her feelings instead
of by “externally derived shoulds”? On what epistemological basis can
Dr Schwartz claim that clients will function optimally if adopting the
ethical philosophy of elegant RET?
Different people propose very different answers to these questions
(Sinnott-Armstrong and Timmons 1996). Unless working with a
homogeneous population, therapists are likely to encounter clients who
use different approaches to ethical knowledge. In this section, I will discuss
eight approaches, several of which contain very dissimilar subtypes, and
most of which can be combined in some fashion.
Knowledge through tradition
Some turn to the answers provided by tradition, whether religious,
secular, professional, or some combination thereof. If I want to know
what ought to be done, I learn the answers traditionally given. Although
psychologists join with philosophers in roundly rejecting the idea that
people should uncritically accept tradition, tradition may well be the
most significant source of ideas about what is good, right, and virtuous
for most people. And, as noted earlier, we tend to be shaped far more
than we are aware by the ethical traditions in which we are immersed.
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 71
Tradition thus shapes the “knowledge” obtained by advocates of each of
the following positions.
Knowledge through reason alone
The Ancient Greek philosophers challenged a reliance on tradition,
arguing instead that reason should be used to obtain ethical knowledge.
In the Enlightenment, reason regained ascendancy, and efforts to obtain
knowledge through reason alone continue (e.g. Donagan 1977; Gert 1975,
1988; Toulmin 1950). But others, most notably Nietzsche and some of his
postmodern intellectual heirs, have reacted strongly against reason.
MacIntyre, who labels efforts to found ethics on reason or other “certain”
foundations as “the Enlightenment project”, asserts that:
Nietzsche jeers at the notion of basing morality on inner moral
sentiments, on conscience, on the one hand, or on the Kantian
categorical imperative, on universalizability, on the other. In five
swift, witty and cogent paragraphs he disposes of both what I have
called the Enlightenment project to discover rational foundations
for an objective morality and of the confidence of the everyday
moral agent in postEnlightenment culture that his moral practice
and utterance are in good order.
(MacIntyre 1984:113)
Three responses to Nietzsche’s challenge are common: affirmative
postmodernists claim that modest ethical knowledge, although difficult
to obtain, is possible; skeptical postmodernists reject the possibility of
moral knowledge; and others (who may reject the implicitly ethical
categories “premodern, modern, and postmodern”) continue to assert
that ethical knowledge is, in some fashion, obtainable through reason.
Knowledge through the scientific method
Scientifically-oriented psychotherapists tend to be suspicious of those
who rely on reason alone, seeing that as mere “armchair philosophizing.”
They turn instead to science to provide knowledge. Although many who
are devoted to science (especially when they understand science through
the lens of logical positivism) argue that ethical knowledge is an
impossibility, others look to science as a source of ethical knowledge.
Accordingly, to answer the ethical question “what kinds of therapy, and
how much therapy, should Health Options reimburse?”, Health Options
established a panel of scientists. They relied upon scientifically derived
data to determine the types of acceptable therapy (those empirically
supported) and the limits for such therapy (the number of sessions clients
72 ETHICAL THEORIES IN PSYCHOTHERAPY
with a particular problem typically take to respond to treatment). They
thus argue that science can tell us which forms of therapy work and that
knowledge can answer the ethical question of the proper level of
reimbursement for therapy.
That simple use of science to make ethical decisions needs to be
distinguished from more sophisticated efforts to use science in decisions
about practice (see Hayes et al. 1995; Kendall and Chambless 1998;
Nathan and Gorman 1998; Roth and Fonagy 1996; and the discussion in
Chapter 6). Kendler, for instance, argues that, while “psychology is
unable to validate moral principles because of the logical impossibility of
inferring ethical imperatives from empirical data” (Kendler 1993:1046), it
can contribute to policy decisions by making evident the consequences of
alternative proposals.
Another attempt to provide ethical knowledge based on science has
been mounted by sociobiologists and others whose conception of science
is closely tied to materialistic metaphysics and a particular understanding
of evolution. They argue that we can know what should be done by
carefully thinking about evolution, the aim of which is (the nonmoral
good of) survival. The ethical theory which results is a defensible form of
utilitarianism, in which the well-being of society and the earth
(controversially equated with the survival of the human species) is the
criterion used to determine what should be done. Clearly, however,
ethical conclusions reached in this way are not determined by science
alone, but by an understanding of evolution in combination with a
particular metaphysical commitment and an ethical allegiance to species
survival as the highest good. Science as empirical endeavor is thus joined
with an extensive set of philosophical commitments. As such,
sociobiologists are better characterized as striving to obtain ethical
knowledge through an implicit combination of reason, nature, and
ethical conviction.
Knowledge through an explicit combination of reason
and nature
Some classical approaches to ethical knowledge explicitly combine
assumptions about human nature (as understood from a particular
philosophical perspective) and reason. To varying degrees, these positions
are open to revision based on experience with actual, not hypothesized,
nature (although a theory-free grasp of “actual” nature is difficult or
impossible to achieve).
Aristotle’s ethical theory holds that human beings achieve happiness
and goodness by behaving in harmony with their essential nature, which
is rationality, the end or telos to which human beings, by nature, should
move. Nature and reason are thus essential both to human beings and to
ethics. Aristotle adds, however, that the person with moral vision, who
can know what is good, right, and virtuous, and behaves accordingly, is
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 73
the virtuous person. So, to know what is good, one must be good. And
virtue is shaped by habits conducive to goodness.
In addition, some religious ethical positions, based on “natural law,”
hold that by examining nature, including human nature, we can know
what human beings, as created by God, should do.
Knowledge through extra-rational personal qualities
Tania’s implicitly encouraging to Sandra to “get in touch with her
feelings” is but one example of a heterogeneous spectrum of approaches
to ethical knowledge that have this in common: extra-rational (meaning
beyond or outside of reason, not necessarily irrational or anti-rational)
aspects of a person can produce trustworthy knowledge about what is
good, right, or virtuous. An early example may be found in Pascal’s
assertion that, “the heart has its reasons, which reason does not know”
(1958:78).
Romanticism, with its roots in a response to the Enlightenment,
stressed culture and instinct (with a meaning different from that of
contemporary biology) as critical sources of knowledge and identity.
Those in this tradition hold radically different positions. On the one hand,
some humanistic psychologists (see L.A.Sass 1988) make eloquent
appeals stressing the goodness of human nature, the trustworthiness of
feelings, and the positive benefits to individuals and society of trusting
the “organismic valuing process” (Rogers 1964). On the other hand are
those who stress the feelings associated with one’s racial group (instinct
and culture) found in “the Nazi cry to think with the blood” (MacIntyre
1966:75).
Other Western ethicists have also stressed ways of knowing what is
good, right, and virtuous that do not use, or emphasize, reason. Some, for
example, David Hume, emphasized “moral sense,” a “faculty” involving
emotions or sentiments by which we know what is right and wrong
(Kurtines et al. 1990). Scottish Common Sense Realists stressed
“conscience” as a way to make ethical distinctions (Sprague 1967). And
intuitionists have stressed that we know intuitively what is good, right,
and virtuous. Since these positions have significantly influenced Western
culture, clients often hold them.
Finally, existentialists argue that only those moral decisions that are
freely chosen, or authentic, can be called moral. Accordingly, one knows
what is right only through a process of authentic choice.
Knowledge through divine revelation
This general approach to ethical knowledge can take several forms.
Sandra’s belief in her obligation to care for her father came in part from
her black Pentecostal tradition, which holds that God’s will, as revealed
through Scripture and the inspiration of the Holy Spirit, produces
74 ETHICAL THEORIES IN PSYCHOTHERAPY
knowledge about what is good, right, and virtuous. William James (1978)
noted that adherents of a variety of religions report experiencing mystical
states that include a noetic component. Others claim different forms of
direct, unmediated knowledge of God’s will.
Many Jews, Christians, and Muslims view sacred scripture as a
compendium of (or otherwise revealing) the divine will. This can take
primitive forms, like a person closing his or her eyes, opening up a Bible,
and randomly putting his or her finger down to discern “God’s will.” But
there have also long been thinkers who have combined reason with
Scripture. For instance, Moses Maimonides, a medieval Jew, combined
Aristotelianism with Jewish Scripture and tradition in formulating an
ethical position (Maimonides 1975a, 1975b). And, in a position now being
revived (e.g. MacIntyre 1988, 1990), Thomas Aquinas combined
Aristotelianism with Christianity in his “Great Synthesis,” producing
seven virtues—courage, justice, practical wisdom, temperance, faith,
hope, and love—the last three requiring revelation to be known. And
very sophisticated intellectual accounts of ethical knowledge that rely, in
substantial measure, on Scripture continue to be espoused (e.g. Adams
1987; Hays 1996; Mouw 1990; Quinn 1978).
Knowledge arising out of relationships
Some argue that knowledge about what is good, right, and virtuous
arises only within the contexts of relationships, relationships producing
forms of knowledge otherwise unobtainable. MacIntyre (1984) argues that
human beings achieve such knowledge by being rooted in particular
communities. What is distinctive about recent history is not that we lack
such communities but that our present community asserts, contrary to
fact, that individuals cut off from community can obtain ethical
knowledge.
In addition, feminist ethicists have emphasized the importance of
relationships. Noddings (1984), for instance, sees in relationships a source
of knowledge about caring, about how we should live. Other feminists
(e.g. Friedman 1991; Hoagland 1991), however, criticize those who see
traditional relationship patterns as a source of moral knowledge when
those patterns harm women.
Some religious ethicists have also argued that ethical action, and
consequently knowledge, arises out of a relationship with God (Long
1967). Faith involves personal transformation, which leads to changed
behavior, like that following a person falling in love.
Knowledge through hermeneutics
Finally, Guignon (1993), MacIntyre (1984), Richardson and Woolfolk
(1994), L.A.Sass (1988), Taylor (1989), Vitz (1990), and others have argued
that ethical knowledge is rooted in the interpretation of narratives,
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 75
stories, and other forms of discourse. We make sense of our existence, we
know what is good, right, and virtuous, by the understanding we
develop through hearing, telling, and interpreting stories. As Guignon
notes, the stories or narratives we construct “have a ‘moral’ to the extent
that their resolution implies the achievement of some goods taken as
normative by our historical culture” (Guignon 1993:236). We learn to
become therapists (learn what ought to occur in therapy) by hearing
stories about therapy conducted by master therapists, by a careful review
in supervision of what actually happens (told in narrative form) in
particular therapy sessions, and by listening to clients who rely heavily
upon stories to tell about themselves and their problems. Psychotherapy,
on this account, is an attempt to recraft the stories of clients who have
gone astray: clients (rather than events or other people) begin to author
their stories. Clients move in the direction of a final chapter of their own
choosing, that is, toward a better, more good, or more right concluding
chapter. Stories are thus held to be a vitally important way in which
therapy participants obtain ethical knowledge.
Those who stress the importance of narratives also stress the
inescapability of the hermeneutic task of interpreting those stories. They
would argue that to obtain ethical knowledge relevant to Sandra’s
therapy, we must interpret the story of Sandra’s life as a whole, including
the role of therapy within that emerging story. Telling Sandra’s story
includes an account of her striving to be honest at work, getting anxious
when told to lie, striving to be a good wife, good daughter, and good
homemaker, and becoming depressed by her failure to fulfill all of those
roles satisfactorily. The end of her story is unresolved, but “the end” of
her story will most likely be “happy” if it “makes sense” in terms of the
story that began long before she entered therapy and if she is an active
participant in its “writing.”
To conclude, people employ a wide variety of approaches to obtain
ethical knowledge. A few clients and therapists may articulate such
epistemological positions explicitly. But it is more likely that they
“operate with a partially articulated and somewhat incoherent set of
vague general principles…and unexamined ethical intuitions” (Meehl
1981:6). And, of course, many employ mixed ethical models, relying upon
more than one source of knowledge about ethics.
Ethical theory in relationship to religion
In a previous age, many people simply assumed that religion was the
appropriate basis for ethics. By way of contrast, some now think it
inconceivable that an adequate ethical theory could be based on religion,
spirituality, or both. These polarities are also present in clients and
therapists: some cannot imagine approaching questions of good and bad,
right and wrong, virtue and vice, from any but a spiritual or religious
76 ETHICAL THEORIES IN PSYCHOTHERAPY
perspective. But others assume that to turn to religion or spirituality in
the realm of ethics is to choose superstition, falsehood, and irrationality.
Sandra exemplifies the first approach; Dr Schwartz the second. And
Tania occupies an uneasy position between them.
In this section, I will address the following question: is it sometimes
necessary—if we want to understand the ethical theory employed by
clients and therapists—to include a consideration of religion and
spirituality?
One could conclude, after reading some psychotherapy literature, that
religion is extinct. But empirical research indicates that a consistent 95
per cent of Americans believe in God, with 88 percent reporting that they
pray (Hoge 1996). However, the role of religion has changed for many
people. As Hoge notes, “religion is as alive as ever, but it is diversifying”
(Hoge 1996: 38). Accordingly, psychologists of religion argue that we best
understand religiousness from a multi-dimensional perspective (Hoge
1996; Hood et al. 1996; Wulff 1996). Two important ways in which religion
is diversifying, notes Hoge, are a waning of denominational loyalty and
the increasing privatization of religion, a change perhaps reflected by the
fact that many prefer to think of themselves as “spiritual” but not
“religious.” But if spirituality is a private matter, therapy is supposed to
be a place to talk about “private” issues, and so should address
spirituality when relevant to a client’s therapeutic progress.
The fact that many people consider themselves religious or spiritual
may, however, be irrelevant to the concerns of this chapter, because
religion and spirituality may be unrelated to ethical theory. This would
certainly be the case if Dr Schwartz were conducting therapy with a
client whose views on religion mirrored his own: religion plays no role in
their lives. But religion was vitally important for Sandra, as is the case
with many African-Americans (Boyd-Franklin 1989). And religion was
clearly linked to her ethical theory. Rejecting relativism, she believed that
God is in some way the basis for what is good, right, and virtuous. She
believed she should exhibit virtues consistent with being a good wife and
daughter, and that she had certain (deontological) obligations to her
husband and father. She had knowledge of those obligations because
they had been revealed through Scripture, the direct inspiration of the
Holy Spirit, and the words of the male and female preachers, inspired by
the Holy Spirit, whom she heard at her church.
By way of contrast, spirituality played a minimal role in Tania’s ethical
theory. She had embarked on a very private spiritual journey whose
primary ethical implication was her desire to respect and learn from
others.
Although 95 percent of Americans believe in God, only 47
percent “consider faith to be relevant to the way they live their lives”
(Shafranske and Malony 1996:565). To understand in depth the ethical
theories of that 47 percent, however, it may be necessary to consider
religiousness. As Shafranske and Malony note, “in keeping with their
belief and value commitments, religions provide prescriptions for living”
THE SPECTRUM OF ETHICAL THEORIES IN PSYCHOTHERAPY 77
(ibid.: 570). In addition to the specific ethical content found in those
prescriptions, a religion may—from some perspectives—provide a basis
for goodness, moral obligation, and virtue, and provide an approach to
moral knowledge.
We can therefore conclude that, since some therapists and many clients
base their values, and their ethical theory, in some substantial measure on
their religious or spiritual convictions, no account of values and ethics in
therapy that claims to be adequate and comprehensive can ignore
religion and spirituality. We sometimes need to address religion and
spirituality; sometimes we do not.
To understand well the relationship of ethical theory and spirituality/
religion, careful assessment of religion and spirituality is necessary
(E.W.Kelly 1995b; Lovinger 1996; Richards and Bergin 1997). Particular
religious traditions approach ethical questions in a variety of ways.
Indeed, there is rarely unanimity within the major world religions. Long
(1967, 1982), for instance, has set forth a classic taxonomy of how
Christians have addressed ethical issues. Some focus on reason as the sole
or primary source of ethical standards. Others focus on ethical
prescriptions deriving from God, as revealed through Scripture, the
community of the faithful, or both. Still others believe that virtue and
good or right behavior arise out of a relationship with God that transforms
people.
Jewish ethicists are also divided about whether to rely on reason or on
authoritative tradition. Kellner (1978) and Jacobs (1978), for instance, note
that some Jewish writers have focused on reason as a source of Jewish
approaches to what is good, right, and virtuous, but others have focused
upon divine commandments, as revealed in sacred writings. Also
controversial is the existence of a Jewish ethics independent of the
Halakha, or Law (Lichtenstein 1978). Different Jewish groups give different
answers. To the extent a particular client says “For me, there is no ethics
independent of the Halakha” of course, a therapist’s failure to understand
the Halakha and its associated ethical theory will mean he or she will fail
to understand how the client approaches questions of mental health and
morality.
Other religious traditions may also influence an individual’s approach
to addressing ethical issues in psychotherapy (E.W.Kelly 1995b). Amore
(1973), for instance, discusses how Theravada Buddhism involves moving
toward a Path or goal, which includes morality.
Conclusion
Therapists and clients alike answer the questions of ethical theory in a
wide variety of ways. The questions posed in ethical theory are definitely
daunting—yet an awareness of our own implicit and explicit answers to
them is vital. Effective therapy for Sandra, and for other clients, requires
no less.
5
Unpacking diverse understandings of
“values”
“Values” is a remarkably elastic term, put to use by psychotherapists,
psychologists, sociologists, philosophers, and the general public in a wide
assortment of ways. Many also use the term to talk about and understand
the ethical dimensions of psychotherapy. For example, upon hearing
about Sandra’s therapy (the example discussed in Chapter 4), a therapist
may remark:
Well, I don’t believe therapy is value-free. Values are clearly
involved in Sandra’s therapy with Tania. And so Tania will need to
be aware of her own values so she doesn’t impose them on Sandra.
But that’s all that’s needed. There’s no need for philosophical
ruminations about “ethical theory” and the like.
I take issue with those sentiments on several grounds. The literature
addressing values and the role of values in therapy offers far more
practical and theoretical benefit to therapists than that. And it is never
possible to sunder “values” entirely from ethical theory. Indeed, on some
accounts of “values,” ethical theory and values are inextricably bound.
Finally, focusing solely on “values” to understand the ethical character of
psychotherapy is problematic because the term is used in so many
different ways. Encouraging therapists to be “aware of values” is not
helpful unless we clearly define “values.” We need to move beyond
recognizing that “Therapy is not value-free” to a well-developed
understanding of the ways in which it is value-laden. That requires
conceptual clarity.
For all those reasons, I am convinced that understanding the ethical
character of therapy will benefit from a clarification of the many meanings
of “values.”
In the face of the variety of definitions of values, we can adopt several
approaches. Unfortunately, two of the most common—denial of that
variety and “my definition is best, so I can ignore the others”—are
decidedly unhelpful. A better approach exists and should be adopted.
Accordingly, in this chapter, in addition to attempting to clarify the
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 79
multiple meanings of values, I will argue for a particular approach to the
problem of multiple understandings of “values.”
In the final section of the chapter, I will draw upon that discussion of
“values” in a brief review of psychological research on the role of values
in therapy. I will focus on findings pertinent to understanding the ethical
dimensions of therapy, findings that are not always intuitively obvious.
Multiple (theory-laden) meanings of “values”
In 1914, Ralph Barton Perry pointed to a problem which those who seek
to understand “values” still face:
One can not collect values as one can collect butterflies, and go off
into one’s laboratory with the assurance that one holds in one’s net
the whole and no more than the whole of that which one seeks.
There is no perforation about the edges of values to mark the line at
which they may be detached.
(Perry 1914:141)
Because of the shapelessness of “values,” Maslow suggested that the term
can be thought of “as a big container holding all sorts of miscellaneous
and vague things” (Maslow 1963a: 120). Consequently, “values” is used
in so many different ways that, if not careful, we can end up being more
confused than clear.
Suppose, for example, that a group of people discusses “Sandra’s value
of ‘a good marriage.’” One person might understand that to mean her
feelings about marriage, another her thoughts about it, another her
behavior, and a fourth all three (with none addressing what is actually
good, right, or virtuous). And others may think that that value (if
authentic) reflects her own choice, or is an outgrowth of who she, at the
deepest level, really is as a person. Still others may think “value” reflects
attempts by the Fundamentalist Christian preachers of her childhood to
impose upon Sandra their patriarchal religious ideology. “Her value is a
product,” others might assert, “of her particular cultural and historical
background.” Finally, some may use it as an ethical term, in accord with
some of the philosophical approaches discussed in Chapter 4.
A taxonomy of definitions of “values”
Those assumptions about the meaning of Sandra’s “values” illustrate
some important differences among types of definitions of values. Those
differences can be summarized in the following taxonomy:
• values as psychological
• values as ethical
80 ETHICS AND VALUES IN PSYCHOTHERAPY
• values as a means by which the powerful impose their will on the
weak
• values as choices
• values as authentic expressions of an individual’s nature
• values as cultural and historical.
A word of qualification is in order: many definitions combine one or
more of those emphases. Also, I will not address distinctions between
definitions of “values” that would be important for other purposes. Much
is to be gained by using those “richer” definitions and distinctions; I
focus here on key distinctions that shed light on how the term “values” is
used to understand the ethical dimensions of therapy. To make the
taxonomy more useful, I will address each of those six types of definition
in turn.
Psychological definitions of “values” emphasize a variety of
psychological concepts: cognitions, affect, behaviors, motivation, social
influence, attitudes, traits, and so forth. Skinner, for example, asserted
that “to make a value judgment by calling something good or bad is to
classify it in terms of its reinforcing effects” (Skinner 1971:105). Sandra’s
valuing a good marriage would thus mean “behaviors associated with
marriage are positively reinforcing to her.”
Other psychologists emphasize different psychological concepts. When
psychoanalysts “study values,” Michels (1987) notes, “they mean that
they trace their developmental roots, hidden meanings, and psychic
significance” (Michels 1987:42). The psychoanalyst’s interest in Sandra’s
“value” regarding marriage would accordingly be directed toward its
childhood origins and unconscious meanings. Others emphasize emotions
when discussing values. Fishbein and Ajzen (1975), for instance, treated
“evaluation” and “affect” as synonyms. Rokeach (1973) focused on
values as a particular type of belief. And still others (e.g. Rest 1984), in
attempting to provide a full account for morality, address cognition, affect,
and behavior.
According to psychological definitions, then, values are what people
value, judge to have value, think to be good, or desire (Frankena 1967:230).
Frankena additionally notes, however, that others employ a second type
of definition of values:
what has value or is valuable, or good, as opposed to what is
regarded as good or valuable. Then “values” means “things that
have value,” “things that are good,” or “goods” and, for some
users, also things that are right, obligatory, beautiful, or even true.
I refer to this as an ethical definition of values.
Kitchener described the contrast between psychological and ethical in
this way: “There is an important distinction between what one’s client
actually desires and what is desirable or ought to be desired by one’s
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 81
client” (R.F. Kitchener 1980b: 15). In making similar distinctions,
Peperzak (1986) contrasted factual and normative meanings of values,
and J.P. Johnson (1967) the descriptive and the normative sides of value
questions. I use the labels “psychological” and “ethical” because in the
former type of definition, “value” pertains to some psychological
process, to valuing. Psychologists, including those who conduct
empirical research on “values,” generally employ some type of
psychological definition. I label the second type of definition of values
“ethical” because such definitions address “an arena traditional to
philosophical ethics” (Rescher 1969’ 55).
Some who employ psychological definitions of values aspire to exclude
the ethical from their definitions. Skinner, for example, clearly
differentiated his psychological understanding of “values” from the kind
of classical understandings of ethics I discussed in Chapter 4:
The behaviors classified as good or bad and right or wrong are not
due to goodness or badness, or a good or bad character, or a
knowledge of right and wrong; they are due to contingencies
involving a great variety of reinforcers, including the generalized
verbal reinforcers of “Good!” “Bad!” “Right!” and “Wrong!”
(Skinner 1971:113)
And Rokeach (1973) argued that definitions of values “should avoid”
words like “ought” and “should”, words many regard as quintessentially
ethical. Indeed, in the context of delineating the requirements for a
scientifically fruitful conception of human values, Rokeach made the
rather remarkable assertion that such a conception “should represent…a
value-free approach to the study of human values” (Rokeach 1973:3,
emphasis added).
In contrast to those whose psychological definitions of “values” eschew
(or claim to eschew) the ethical altogether, most users of ethical
definitions of “values” acknowledge the psychological dimensions of the
term but focus on the ethical. They thus employ mixed ethicalpsychological definitions of “values.”
Some psychologists also employ ethical definitions of values. The
preamble of the Ethics Code of APA, for example, states: “This Ethics
Code provides a common set of values upon which psychologists build
their professional and scientific work” (APA 1992:1599, emphasis added).
“Values” clearly refers, not just to the products of psychological
processes of valuing, but to the goodness and rightness of those values.
Compare also psychologist Isaac Prilleltensky’s definition of values: “I
define moral values as benefits that human beings provide to other
individuals and communities. Thus, I treat values as entities, ideas, or
predispositions to action that have the potential to promote the good life
and the good society” (Prilleltensky 1997:520).
82 ETHICS AND VALUES IN PSYCHOTHERAPY
By way of contrast, some assert that, even if there is “a good life,”
human beings cannot know what it is. “Values” are accordingly viewed
with considerable suspicion: they are understood to be a means by which
the powerful impose their will on the weak. Some postmodernists would
thus assume that Sandra’s “value,” a good marriage, is really about
attempts by the Fundamentalist Christian preachers of her childhood to
impose upon Sandra their patriarchal religious ideology. Such
postmodernists would “deconstruct” her value claims, understand them
in terms of power, and be suspicious of any ethical claims made on
behalf of that or any other “value.”
Accordingly, some advocates of this third type of definition, like some
who use ethical definitions, take a clear stand on the issues of ethical theory
discussed in Chapter 4. Other users of this definition, like Kristiansen and
Zanna (1994) in their aptly titled article, “The rhetorical use of values to
justify social and intergroup attitudes,” assume that stated values can be
used as rationalization, to justify discrimination, or for defensive
purposes. They do not, however, assume that values are “nothing but”
efforts by the powerful to impose their will on others.
A fourth set of users of the term understands “values” in terms of
freedom. If Sandra’s value is genuine, she must have chosen to adopt it,
although she could have done otherwise. A person is never coerced into
holding a true value, not coerced by others and not coerced from within
by psychological forces—whether by biological determinants, by
reinforcement history, or by unconscious determinants. Dickson (1994),
for instance, adopted a Sartrean perspective and argued that freedom is
“the source of all value” (Dickson 1994:15). Advocates of this definition
reject the claims of psychological researchers who assert that values are
the products of psychological processes that can (in principle) be
described in scientific laws. They hold that values are chosen, not
determined. On this understanding of values, then, human decisions
“create” values (MacIntyre 1984; Perry 1914).
Still others assert that values, true values, are authentic expressions of
an individual’s nature. Self-actualized persons, asserted Carl Rogers,
learn to “live by values which they discover within” (Rogers 1961:175).
Similarly, Nerlich (1989) argues that values can be correct if they emerge
authentically from a person’s nature. Although often associated with
definitions emphasizing freedom, this type of definition is different:
Maslow, for instance, flatly rejected the Sartrean position that we possess
unbounded freedom to choose our own values. He asserted that “human
nature carries within itself the answer to the questions: How can I be
good; how can I be happy; how can I be fruitful?” (Maslow 1987:60).
Maslow might have suggested, for example, that if it was not in Sandra’s
nature to value authentically a good marriage, no amount of choosing
could make it authentic for her.1
Although phrased in individualistic terms (and often understood as
focusing solely on the uniqueness of the individual’s valuing), Rogers
and Maslow claimed a universality for the values healthy individuals
discover within themselves. Rogers, for instance, asserted that, “in
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 83
persons who are moving toward greater openness to their experiencing,
there is an organismic commonality of value directions” (Rogers 1964:165).
The universality of values exists because human beings share a common
nature, an “organismic” nature.
Definitions of values that focus on universal values that arise from
individuals getting in touch with their authentic nature bridge the
psychological-ethical divide I discussed above. They are clearly
psychological in their focus on the subjective psychological processes of
valuing; they also make universal ethical claims about values, albeit
focusing primarily on nonmoral ethical assertions,2 especially the good
life.
I discuss this as a distinct form of definition because humanistic
psychologists regularly distinguish their position from all others. In
addition, the psychological emphases in this type of definition are quite
different from those of researchers studying values within the traditional
empirical paradigm.
Finally, still others employ a sixth type of definition, emphasizing
values as cultural and historical. As Barry Schwartz notes, “values are
often contextually determined, sociohistorical phenomena that can be
created or destroyed by the very beings whose behavior is guided by
them” (Schwartz 1990:7). Sandra’s valuing “a good marriage” could thus
be seen as arising out of a particular cultural context: the world of the
twentieth-century black Pentecostal Church in the midst of an ethnically
diverse US culture that is profoundly shaped by television.
In contrast to ethical, empirical, and humanistic attempts to draw
universal conclusions about values, cultural definitions emphasize that
values are distinctive to the particular cultures and periods of time that
produced them. Values are thus historically and culturally contingent.
Support for this view can be found in the findings of Shalom Schwartz’s
(1994) extensive cross-cultural research program, which has identified
cultural differences among value types.
“Values” thus refers, in Frankena’s words, to “what is valued, judged
to have value, thought to be good, or desired” (Frankena 1967:230). But in
contrast to psychological definitions (in which individuals “value,”
“judge,” and so forth), when cultural-historical definitions of “values” are
employed, cultures in particular historical periods “value,” “judge,” and
so forth.
Individual and cultural values are not, however, easily distinguished,
and “the line between these is elusive” (Kluckhohn 1951:400). The
individualistic training most psychotherapists receive, however, makes it
more difficult for them to see how culture and history shape values than
how individuals shape values. Indeed, we may be shaped by culture and
history much more than we are aware. Part of the challenge of getting at
such values is that they tend to be invisible to the participants in a given
culture and period of time: we may at times be “too close” to such values
to see them clearly. “Some of the deepest and most pervasive of personal
and cultural values,” Kluckhohn observes, “are only partially or
occasionally verbalized” (ibid.: 397). When we change cultural settings,
84 ETHICS AND VALUES IN PSYCHOTHERAPY
or when clients bring other cultures to us, however, we often see clearly
how much culture and history shape our values.
Some view values exclusively in cultural terms; others add a cultural
and historical dimension to different types of definitions, for example, to
psychological or ethical definitions. Accordingly, the cultural and
historical dimension of “values” can be examined whatever definition of
values one employs. Because I think that dimension to be very important,
in Chapters 6 and 7 I will consider some ways in which history and
culture have both shaped and obscured the ethical dimensions of
psychotherapy. And I will consider the history of “values” in the next
section.
The origins of diversity: a brief history of the manifold
meanings of “values”
It was not until 1895 that “values,” in its contemporary
psychologicalphilosophical range of meanings, first entered the Englishlanguage professional academic literature (Werkmeister 1973). And the
German-language origins of those meanings were but slightly earlier. I
want to review briefly the fascinating history of those meanings for two
reasons: to clarify the first five types of definitions discussed above, and
to make clear how some of those differences originated in attempts to
answer certain challenging issues in ethical theory. Those issues (which
we still face today) include the basis of goodness and moral obligation, the
nature of human beings, and ethical knowledge, including the
relationship of science and ethics.
Darwin provoked the crisis that gave rise to the use of “values” in its
present psychological-philosophical range of meanings. Before Darwin,
many concerned with the intellectual basis for ethics (including religious,
non-religious, and anti-religious advocates of Enlightenment ideals and
opponents of those ideals) based ethics on the distinctiveness of human
beings. Kant, for example, accepted scientific efforts to understand nature
(e.g. in the realm of physics—J.P.Johnson 1967), but did not apply the
causal approaches used in such scientific explanations to key aspects of
human beings, whom he saw as unique. He tried to recover the integrity
of morality from certain Enlightenment efforts he thought did not do
justice to morality, focusing on aspects of motivation he thought central
to it. Of relevance to “values,” moral motivation meant being free and “a
radical break from nature” (Taylor 1989:382). Taylor notes as especially
important that “Kant explicitly insists that morality can’t be founded in
nature or in anything outside the rational human will” (ibid.: 364).
In his theory of evolution, Darwin challenged the claims by Kant and
others that human beings are distinct. In Taylor’s words, “natural
science” was introduced “into the very depths of {the} inner nature” of
persons (Taylor 1989:416). Persons, once considered beyond the ken of
science, were no longer.
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 85
Nineteenth-century continental ethicists thus faced a major dilemma,
which Schacht described in these terms:
Their fundamental task was to find some new way of
understanding the nature and place of morality in human life, given
that it can no longer be supposed either to consist of some set of
divine commandments or to have a strictly rational basis and
derivation. They further sought to discover some other basis and
warrant for morality.
(Schacht 1991:516)
Two responses to that dilemma—by the German value theorists and by
Nietzsche—are vitally important in the development of different
meanings of “values.” I discuss them because, as Kockelmans notes,
“Through the work of {the German value theorist} Lotze and Nietzsche,
the notion of value became an essential element of many philosophical
theories, particularly in the domain of ethics” (Kockelmans 1991:524).
And from philosophy, “values” entered psychology.
The German value theorists sought to combine the evaluative problems
in economics, aesthetics, ethics, and religion into one central problem, that
of Value. Their goal was to understand the nature of Value in general so
solutions to the evaluative (values) problems in those fields could be
discovered (Rescher 1969; Schacht 1991; Werkmeister 1970). To
accomplish that task, they borrowed a term, “values,” previously used
primarily in mathematics (Kockelmans 1991), economics (Kockelmans
1991; Pepper 1950; Werkmeister 1970), and aesthetics (Kockelmans 1991).
Of central importance for my purposes, the German-speaking value
theorists used “values” in a way that affirmed both science and
traditional ethical convictions, and also took into account Darwin’s
challenge to traditional accounts of morality.
The value theorists were, however, by no means unified in their
answers to the common problems they addressed. The doctrine of Lotze
“set up a dualism of two realms, that of fact (or being) and that of value”
(Rescher 1969:50), with both included in his concept of “validity.” His
followers, who evinced a clear commitment to philosophical Idealism,
sharply distinguished between scientific methodologies and
methodologies employed in the humanities (Edel 1991; Tillich 1959).
By way of contrast, the value theorists associated with Brentano
affirmed the relevance of empirical methods for understanding values.
And they deemphasized the dualism associated with Lotze’s school
(Rescher 1969). J.P.Johnson notes that those in Brentano’s school rejected
“any purely speculative or metaphysical resolution of the value question
[and} demanded that the question be brought to the forum of empirical
science, in particular the science of psychology” (J.P.Johnson 1967:67).
Psychology was important because these value theorists focused on the
psychological processes giving rise to values: human responses (e.g. love,
86 ETHICS AND VALUES IN PSYCHOTHERAPY
hate, desire, and emotions) to life experiences produce knowledge of
values. (Value theorists debated about which psychological processes
were most important to valuing.) These value theorists thus made two
central assertions: we can pursue empirical, psychological analyses of
values because human beings value (J.P.Johnson 1967; McAlister 1982).
And we can make ethical claims; we can “elucidate objectively
apprehensible intrinsic values” (Schroeder 1991:529).
In other words, these German value theorists adopted a psychological
approach to values which was broadly empirical and which they believed
eventuated in correct ethical judgments. Their concept of values grew out
of their commitment both to science and to ethical realism. Their
ambitious, very difficult intellectual endeavor thus attempted to bridge is
and ought, fact and value, description and evaluation. The tension, the
“opposition of the descriptive and normative ways in value philosophy”
(J.P.Johnson 1967:70), still exists in contemporary value theory. And in
the term “values.”
In terms of the taxonomy of definitions of “values” I set forth earlier in
this chapter, the value theorists’ definition of “values” wove together
psychological and ethical elements. Subsequently, of course, those
threads frequently unraveled. But both those employing psychological
approaches to “values” and those emphasizing ethical approaches can
find in the value theorists their intellectual forebears.
In contrast to the German value theorists, Nietzsche sharply attacked
both Darwin (Werkmeister 1970) and traditional morality (MacIntyre
1984). The term he shared with the value theorists, “values,” played a
central role both in his critique of existing morality and in the
constructive alternative he proposed (Alderman 1991; Frondizi 1963). But
that critique and proposal introduced new definitions of “values,”
definitions different from those of the value theorists.
Nietzsche rejected both religion and Enlightenment moral philosophy,
arguing that they are profoundly inadequate bases for morality. He saw
clearly, Johnson (1967) asserts, that:
{existing} value ideas and judgments merely describe the conditions
of their emergence and development in consciousness and function
as instruments in the service of natural life and existence. They do
not sustain any objective import bearing upon a metaphysical order
of value and man’s relation to that order.
(J.P.Johnson 1967:64)
But Nietzsche also asserted that if we adopt a scientific approach (like that
of Darwin) to understand human beings, including human values, we
face a major problem: “Now that the lowly origin of these values
becomes known, the whole universe seems to have been transvalued and
to have lost its significance” (Nietzsche 1909:10). Consequently, “man has
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 87
lost an infinite amount of dignity” (ibid.: 19). That, cried Nietzsche, was
intolerable (Werkmeister 1970).
Nietzsche’s “diagnosis” led him to a clear understanding of the
philosopher’s task. As Detmer interprets Nietzsche’s views: “We cannot
live without values, but we cannot live with the values of the present. Thus,
we must destroy these values of the present and create new and better
values for the future” (Detmer 1989:277).
Nietzsche’s use of “values” thus exhibits both a critical side (“destroy”)
and a constructive side (“create”). Because some people influenced by
him emphasize the critical side and others emphasize the constructive,
more than one definition of “values” can be traced to Nietzsche.
Nietzsche strove “to unmask false candidates for the role of the new
morality” (MacIntyre 1966:223). As critic, he vigorously attacked
Christianity, the emancipation of women, democracy, socialism,
Platonism, utilitarianism, traditional value standards, hedonism, and
human equality (Berkowitz 1995; Werkmeister 1970). Taylor argues that
it was of particular importance that Nietzsche, “taking a fateful turn
against the Enlightenment, declared benevolence the ultimate obstacle to
self-affirmation” (Taylor 1989:343).
Nietzsche was a very effective critic. Indeed, MacIntyre (1984) has
argued that Nietzsche definitively demolished the Enlightenment project
of finding a modern, objective justification for morality:
It was Nietzsche’s historic achievement to understand more clearly
than any other philosopher…not only that what purported to be
appeals to objectivity were in fact expressions of subjective will, but
also the nature of the problems this posed for moral philosophy.
(MacIntyre 1984:113)
Skeptical postmodernists have interpreted Nietzsche’s critical side to
mean that societal efforts to justify morality are, in fact, nothing but one
party attempting to gain power over another. Taylor notes, for example,
that the neo-Nietzscheans Foucault and Derrida focus exclusively on
Nietzsche’s critical side, especially “on Nietzsche’s sense of the
arbitrariness of interpretation, on interpretation as an imposition of
power” (Taylor 1989: 488). Neo-Nietzscheans thus “deconstruct” ethical
assertions, doing so in accord with their definition of “values”: “a means
by which the powerful impose their will on the weak,” the third type of
definition of “values” discussed above.
But to focus exclusively on Nietzsche’s critical side is to ignore
the constructive proposals he made (Berkowitz 1995). Stemming from his
radical diagnosis of the human dilemma, Nietzsche’s “cure,” MacIntyre
notes, was for individuals “to transcend the limitations of all hitherto
existing systems of morality, and by a ‘transvaluation of values,’ to
prophetically introduce a new way of life” (MacIntyre 1966:223).
88 ETHICS AND VALUES IN PSYCHOTHERAPY
But there are at least two interpretations of what such a
“transvaluation” or “revaluation” of values entails. One interpretation
emphasizes the unconstrained autonomy of the individual to choose
values; the second emphasizes creativity, stemming from an individual’s
nature, as the basis for transvalued values.
On the first understanding of Nietzsche, values are chosen. Values are
not “discovered” because, as Kaufmann put it, “there is no meaning in
life except the meaning man gives his life” (Kaufmann 1967:512). If
marriage was truly a value for Sandra, for example, it was only because
she chose to value it, not because it possesses any inherent worth or
goodness. Morality, for Nietzsche, is what the will of the autonomous
individual heroically creates (MacIntyre 1984). Nietzsche thus understood
“values” to be the free, unique, and unanalyzable creations of the
individual, the heroic expressions of the human will. About those
“values,” neither metaphysics nor moral tradition, neither Christianity
nor science, has anything to say.
The second interpretation of Nietzsche’s constructive ethical proposals
is subtly, yet significantly, different. The emphasis is not on the will of
the autonomous individual creating new values, but on the creativity of
the individual (Schacht 1991), with creativity arising from the
individual’s nature, not simply from his or her choices. Nietzsche thus
proposed a “naturalization” of morality (Schacht), with a person’s nature
seen as the genesis of values. This naturalization can be seen in
Nietzsche’s concept, “will to power,” which produces values and which
Nietzsche saw as an “altogether natural inclination to exert fully one
one’s own force or strength toward some goal” (Alderman 1991:903).
In setting forth this vision of the best possible life for persons, creativity
arising from individuals’ natures, Nietzsche is proposing a normative
ethics (Alderman 1991; Berkowitz 1995). On this reading of Nietzsche,
both the skeptical deconstructionists who focus only on his critique of
existing ethical positions, and the existentialists who think Nietzsche
focused solely on individuals’ choices (an interpretation in which no
general conclusions about the good life can be drawn, because all persons
must choose their own), overlook Nietzsche’s constructive ethical vision.
In developing his normative ethics, Nietzsche drew upon older ethical
traditions and developed a theory about the best life for individuals
(Berkowitz 1995). In proposing these transvalued or revalued “values,”
Nietzsche thus appears to be using an ethical definition of the term.
But Nietzsche’s is a limited and idiosyncratic theory of ethics and,
hence, understanding of “values.” Morality and values stem from the
nature of creative human beings, and so are, in a sense, objective. But that
nature is contingent. That is, the nature from which values arise is
dependent on the circumstances of the individual person. As Schacht
points out, Nietzsche’s naturalization of morality:
acquires an objective basis in reality, even if a contingent one, since
these are matters reflecting characteristics human beings actually
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 89
possess as the living creatures they are. But morality thus
“naturalized” is pluralistic as well as contingent, since human beings
differ significantly in their constitutions, in their ability and
potential, and in what their optimal flourishing and development
require.
(Schacht 1991:521)
The limited and pluralistic nature of Nietzsche’s ethical perspective
means his normative theory and understanding of “values” differ from
those of humanistic psychologists. As discussed earlier in this chapter,
Rogers and Maslow made universal claims about their vision of the good
life. Perhaps in part because he was less influenced by relevant strains
within Romanticism, Nietzsche did not.
Nietzsche’s ethics and definition of values also contrast sharply with
other naturalistic approaches to ethics and values. His emphasis on
autonomy and the individual’s will to power and his understanding of
“nature” (including its contingent and pluralistic character) make his
(idiographic) naturalistic approach to values very different from the
(nomothetic) naturalistic approaches (e.g. Schwartz and Bilsky 1990) of
psychological scientists who use empirical methods to uncover universal
laws or structures pertaining to values. Furthermore, Nietzsche’s
naturalistic ethics is different from that of ethical naturalists who see
evolution as the sole basis for ethics. The ethical ideals they put forth (e.g.
survival and adaptation) are decidedly not a part of Nietzsche’s richer,
more strenuous vision of the good life, a vision that includes spontaneity,
reinterpretation, and creativity (Werkmeister 1970).
By now the reader must wonder, “How is it that Nietzsche can be
interpreted in so many ways: as a critic of traditional values, as an
enthusiastic advocate of the freedom of the autonomous individual to
choose entirely new values, and as a champion of values arising from the
nature of individuals?” Berkowitz’s observation illuminates: “Nietzsche
rejects the very idea of natural or rationally intelligible ends, yet he also
affirms them and cannot do without them; this pervasive tension both
binds his thought together and tears it apart” (Berkowitz 1995:4).
Depending on which strand of Nietzsche one focuses upon, then, his
ethical stance and definition of values will appear to vary.
These tensions in Nietzsche’s thought have left us a rich legacy of definitions of “values” that originated in his writings. From Nietzsche’s
critical side comes a definition of “values” as masked attempts by one
party to gain hegemony over others, as a means by which the powerful
impose their will on the weak. And, depending on how the
“transvalued” values of his constructive side are interpreted, “values”
can mean either the choices of an autonomous, meaning-creating
individual, or the creative act of a person attuned to his or her individual
nature. Nietzsche emphasized all three in his provocative philosophy.
But all three types of definition have clearly influenced some
90 ETHICS AND VALUES IN PSYCHOTHERAPY
psychologists (and clients) in their uses of “values”; all three types differ
significantly both from the definitions of those who measure “values”
with psychometrically adequate psychological tests and from the
definitions of many of those who engage in philosophically sophisticated
theoretical ethics regarding values.
It would appear that others have pried apart what Nietzsche tried
(with but limited success) to hold together in his philosophy. In this
regard, he is like the other source of our current range of psychologicalphilosophical uses of “values,” the German value theorists. Both
introduced “values” and gave the term new sets of meanings as part of
complex, ambitious efforts to solve some fundamental problems of
ethical theory, psychology, and philosophy. Those who use “values” in
one of the senses they did may well be adopting, in part, the ethical
theory for which that definition of “values” was first developed.
Although Americans did not find the intellectual problems Darwinism
posed for ethics as compelling as did the German value theorists and
Nietzsche, the new uses of “values” caught on. Munsterberg, a German
value theorist in the school of Lotze, brought the term to the US from
Germany (Perry 1954; Rescher 1969; Tillich 1959) after his arrival at
Harvard in 1892 as successor to William James. Although his was a
decidedly idealistic and dualistic understanding of values, American
psychologists and philosophers soon began to employ the term in some of
its other uses.
The American use of the European heritage of value theory was
selective. Psychologists focused on the valuing process, on values defined
psychologically. And empirical methods seemed well suited to
understand those “values.” And so, by 1913, Henderson discussed a
“Scale of Values,” which included a distinction between “moral,
intellectual, social, economic, taste, and health values” (Brown 1914: 59).
But what became the Allport-Vernon-Lindzey Study of Values gave the
empirical measurement of values its greatest impetus. Allport (1967),
who was clearly concerned with both psychological and ethical issues,
based his test on six dimensions of values set forth by Spranger, with
whom he had studied in Europe. Those who take the self-administered
test, long one of the major psychometric instruments measuring values
(Braithwaite and Scott 1991), indicate their relative preference for items.
This permits the classification of people in terms of Spranger’s six types of
“values” or “interests”: theoretical, economic, aesthetic, social, political,
and religious (Vernon and Allport 1931). Despite Allport’s interest in
ethics, the test does not ask what respondents should be interested in or
prefer, but only what they do prefer. The test thus employs a strictly
psychological definition of “values,” and fails to tap into the ethical
dimension of “values.” In addition, the test does not address “the
ordering of the six categories of value in respect to their ethical worth”
(Vernon and Allport 1931:232), an explicitly ethical task that Spranger
(1928) tackled.
In the early part of the twentieth-century, then, American social
scientists substantially deviated from the attempts of the early value
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 91
theorists to ground ethics (along with aesthetics, economics, and religion)
in values, and to address the objectivity of the valuing process which
produces such values. The Americans also deviated from the concerns
that led Nietzsche to use “values” in a new set of ways. Psychologists no
longer addressed ethical issues—what is good, right, virtuous, and
valuable—when the word “values” was used. It was, of course, often
possible to address those issues and to measure values as psychologists
did. But that rarely occurs, and the uses of the term are now very fuzzy
indeed.
Reviews of the psychological literature on values (Braithwaite and
Scott 1991; Levitin 1973; Tisdale 1961; Wilson and Nye 1966) reveal that a
wide variety of psychological approaches have been adopted, with
different investigators focusing on different psychological processes or
different aspects of behavior. Braithwaite and Scott noted that few of the
tests of values they reviewed “either provide justification for focusing on
particular facets of the value domain or involve systematic sampling of
items to represent these facts” (Braithwaite and Scott 1991:664).
Psychological approaches to values thus range from approaches closely
related to economic approaches (e.g. Fischhoff 1991; Kahneman and
Tversky 1984) to approaches emphasizing the role of culture and
individuals in creating and destroying values (e.g. B.Schwartz 1990).
Although many of the psychologists who adopted empirical
approaches hoped thereby to sidestep the philosophical issues that
spawned the new uses of “values,” Edel points out that the concept did
not become clarified through those approaches: “What happened was
simply that the different interpretations that had characterized the
general theory of value in philosophy now reappeared in the usage of the
social scientists” (Edel 1988:27). Ethical theory and associated
philosophical issues thus remained in the picture, albeit beneath the
surface of psychologists’ empirical work on values.
Humanistic psychologists developed, or rather, revivified and gave
some new twists to, a set of definitions of “values” with deep roots in
Western philosophy, especially in Nietzsche and Romantic thought
(Browning 1987; Taylor 1989; Wallach and Wallach 1983). They focused
on a person’s freedom to choose values and on values as the products of
one’s true self or inner nature, on values as the products of Maslow’s selfactualizing tendency or of Rogers’ organismic valuing process. Because
of the presumed origin of such values—the experiencing of the
individual subject—empirical tests of such “values” were rare. Indeed,
adoption of this understanding of “values” may be why noted therapy
researcher Hans Strupp lamented, “We don’t know how to research the
problem” of values in therapy (Strupp 1980:397).
In summary, several themes have emerged in this brief review of the
use of “values” in the US:
1 A move toward a descriptive, empirical, psychological approach to
values in academic psychology and a concomitant, inconsistent move
92 ETHICS AND VALUES IN PSYCHOTHERAPY
away from the classical concerns of ethics and from ethical
definitions of “values.” Psychologists thus tend to use psychological
definitions.
2 Definitions of values proliferated: as psychologists have studied
various behaviors and psychological processes, each purportedly
“getting at” what values are “really” all about, new definitions have
appeared.
3 The explicit, extensive philosophical reflections of the German value
theorists and Nietzsche receded into the background, giving way to
implicit ethical theories and the more limited (and often implicit)
metaphysical commitments (and the occasional denials of any
metaphysical commitments) characteristic of the American pragmatic
and empirical traditions.
4 Humanistic and existential psychologists retrieved elements of
Nietzschean and Romantic thought in developing concepts of
“values” focusing on individual choice and on the origin of values
within the subjective experiencing of persons.
Two final developments round out the history of the taxonomy of values:
postmodernists retrieved the critical side of Nietzsche and exhibited
suspicion of any ethical use of “values.” And cultural anthropologists,
crosscultural psychologists, and greater sensitivity to ethnic and other
minorities have produced greater attention to values as cultural and
historical phenomena.
Because of these developments, “values” is used in a wide variety of
ways. And so when a client or researcher uses the term, an essential first
step is to clarify the particular definition of “value” intended.
Values in context
To understand Sandra’s value, “a good marriage,” or to understand the
value of any client, it often helps to know more than the definition of
“value”: we need to know the context of that value. And that is true
however “value” is defined, and whether one employs traditional
empirical methodologies or a hermeneutic approach (Walsh 1995). In a
discussion of professional ethics, Meara, Schmidt, and Day stress context
in even stronger terms: “Espousing values without awareness of context
is usually unproductive and unethical” (1996:32).
Several dimensions of a value’s context may be relevant: the context of
other values, the context of the concrete situation in which the value is
expressed, the clinical context, the cultural context, the context of ethical
theory, and so forth. The context that helps us best understand a
particular value will vary, of course, with why we want to understand it.
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 93
Situating a particular value in the context of a person’s other values is
often very beneficial. For instance, it is more helpful to know “Sandra
values marriage more than she values autonomy” than to know only that
she “values marriage.” Recognizing this, researchers have been
concerned in tests of values with the relationships among values (e.g.
Rokeach 1973;S. H.Schwartz 1992). And Prilleltensky (1997) argues that a
balance among the values endorsed by psychologists is critical. A
commitment to autonomy, for example, is ideally concomitant with a
commitment to social justice.
It has been suggested that “the concrete context of value application”
may also deserve attention (Schwartz and Bilsky 1990:889). Sandra may
endorse “independence” on a test of values, but in the concrete settings
of work and home she may exhibit dependence. Indeed, in their review
of tests of values, Braithwaite and Scott (1991) noted that values (defined
psychologically) are likely to influence the behavior of some individuals in
some situations, but not of other individuals or in other situations.
Accordingly, they urged researchers to explore “the circumstances in
which values are useful in explaining human behavior” (Braithwaite and
Scott 1991:746). And by 1996, Seligman and Katz reported several studies
converging on a single finding: individuals may construct different value
systems in different situations rather than applying one abstract value
system to all situations. That is, as the context changes, individuals’ value
systems may change.
The context of the clinical setting may be particularly important. In a
review of the role of values in therapy, Consoli and Beutler (1996) urged
researchers to examine value issues that arise in actual therapy cases (e.g.
value issues related to divorce). The therapist’s background may be an
especially important element in the clinical context. If Sandra’s therapist
has worked exclusively with battered women for twenty years, had
negative experiences as a child with religion and marriage, views blacks
and women as helpless victims of an oppressive, Euro-centric patriarchy,
and has little experience of a healthy marriage, the role in therapy of
Sandra’s value, “a good marriage,” would likely be quite different than if
her therapist had parents who had had a good marriage, is herself in a
healthy marriage, sees black women as unusually strong and capable,
and has deep spiritual roots. Because those two therapists would be likely
to understand Sandra’s commitment to a good marriage in very different
ways, the role of Sandra’s values in their therapy with her is likely to be
very different. But the client’s background is also an important element
of the clinical context. If a client has a history of enmeshed relationships,
the value of independence may be a very important goal in therapy. But
if the client is unable to form lasting intimate relationships, the
importance of the value of independence may need to diminish in the
client’s life, and that of intimate relationships and sustained love
increase. The role in therapy of the value of independence will thus vary
as the clinical context varies.
In addition, the cultural context of a particular value, although often
difficult to detect, can be very important. Cultural anthropologists and
94 ETHICS AND VALUES IN PSYCHOTHERAPY
others have documented differences among the values held by those in
different cultures (again, no matter how values are defined) and in the
meaning ascribed to particular values. For example, Schwartz and Bilsky,
using empirical measures of values, have found “numerous possible
differences in the meaning of specific values as a function of cultural
context, though perhaps fewer than one might expect” (Schwartz and
Bilsky 1990: 889).
Still other dimensions of a value’s context might be considered
important: understanding a value in the context of a person’s overall
psychological functioning (McClure and Tyler 1967; Strupp 1980), in the
context of the person’s community, in the context of the person’s
biological nature (“embodied ethics”), and in the context of the natural
environment (the concern of environmental ethics).
Finally, an individual’s values can be understood within the context of
a particular ethical theory. In contrast to some modern ethical theories
that see values as belonging within the minds of individuals, Taylor
notes that other ethical theories hold that:
ideas and valuations are…located in the world, and not just in the
subjects…. True knowledge, true valuation is not exclusively
located in the subject. In a sense, one might say that their paradigm
location is in reality; correct human knowledge and valuation
comes from our connecting ourselves rightly to the significance
things already have ontically.
(Taylor 1989:186)
On that account, then, values ought not be sundered from the context of
broader ethical considerations.
But making that assertion brings back the problem of the plethora of
definitions of values, a problem to which I now return.
The problem of multiple definitions of values: a
proposed working solution
In attempting to make sense of diverse understandings of “values,” I face
an interesting dilemma: all the definitions discussed seem legitimate, at
least in some circumstances. Sandra’s values, for example, clearly involve
psychological processes. And so, psychological definitions and
psychological research methodologies (whether quantitative or
qualitative) seem valid. Furthermore, most would agree that Sandra’s
value, “Rape is wrong,” refers to something that really is wrong: rape.
And so ethical definitions seem valid, although the nature and scope of
that validity is widely disputed. Furthermore, it is quite possible that some
people in Sandra’s life have used “values” to impose their will on her.
And most therapists would argue for the importance of “choice” in
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 95
Sandra’s adoption of values and endorse her selection of values that are
consistent with “who she really is” (i.e. with her nature). And, finally,
many would acknowledge a cultural and historical component to her
values.
Given that variety of apparently valid uses of “values,” how do we use
the term “values” to understand the ethical dimensions of psychotherapy?
I want to mention several problematic approaches to the problem of
definition before turning to one I think more promising.
Denying that the term is used in very different ways will not solve the
problem. Nor will failing to be clear about one’s definition. Using the
term in inconsistent ways is particularly problematic, especially using
“values” psychologically but drawing from it conclusions that are ethical.
For example, “My empirical study of values suggests we should….” As I
will discuss in the final section of this chapter and in Chapter 6,
employing empirical methods and psychological definitions of values can
make important contributions to our understanding of the ethical
dimensions of psychotherapy. But doing so requires using “values” in a
consistent way and exhibiting due regard to the complexities of the
science—ethics relationship.
Handy (1969, 1970) and P.Rosenthal (1984) suggested that, given its
many uses, “values” should be avoided altogether. But since clients and
researchers are likely to continue to use it in a variety of ways, that
“solution” seems unrealistic. And avoiding “values” will not solve the
psychological and philosophical problems addressed under the heading
of “values.”
Others faced with the variety of definitions stipulate one definition as
best (Gaus 1990) and may use that definition exclusively, rejecting all
others. A pragmatic reason for not adopting that approach is that other
people—clients, therapists, researchers, and so forth—will likely continue
to use “values” as diversely as ever. Whatever the virtues of any
particular definition, I am not sanguine it would escape the fate of the
best efforts of many others: the definition is politely acknowledged, then
ignored or added to the growing list of extant definitions. But I am not in
favor of the “single definition” solution for another reason: I don’t think
there is one “correct” definition of the term. As discussed above, more
than one definition possesses some validity.
But accepting all definitions can create its own set of problems.
Since those definitions entail decidedly different intellectual claims
concerning “values,” accepting all definitions can mean accepting
contradictory claims. But there is another way to look at the validity of
those definitions: definitions of “values” are valid, not in general, but to
address a particular question, to solve problems in a given arena, or for some
other specific purpose. Although each definition is valid in some way, none
is valid for all purposes. And so we accept different definitions, but accept
each only in part.
If different definitions of values are valid for different purposes, no
definition is useful for all purposes. E.M.Albert’s solution is thus not
96 ETHICS AND VALUES IN PSYCHOTHERAPY
helpful. Defined as “a general label for a heterogeneous class of
normative factors” (Albert 1956:221), her “values” are so abstract they are
not helpful for many particular purposes. Simply listing different
definitions of values is also unhelpful, unless the purpose for which each
is helpful is specified.
The problems with those “solutions” point us in the direction of a better
approach to the problem of diverse definitions of “values”: matching a
definition of “values” with a particular purpose. If a client uses values in a
particular way or set of ways, for example, the therapist should work
within that usage of “value,” at least at the outset. And a researcher
should employ a definition of value that is consistent with the purpose of
his or her inquiry and that is clear. Clarity is important because when a
definition is unclear, the term may be interpreted by people in each of the
ways discussed in this chapter. I think it is also important to take
seriously the valid points made by advocates of various uses of values,
even if one does not employ their definitions. One need not become a
critical postmodernist, for example, to recognize that the powerful can
use the term “values” to impose their will on the weak.
Accordingly, I think it can be legitimate to employ a single definition
of “values,” but only if one is clear about the definition being used and if
other meanings of “values” are taken into account, perhaps by using
other terms for those meanings. For example, the empirical researcher
who employs a psychological definition of values could address ethical
or power issues using terms other than “values,” such as terms like
“ethical” and “power.”
More than one definition can also be used. In any given instance, we
should use the definition that is most most apt. For example, Rescher
pointed out that some valuings are simply a matter of taste (and thus
strictly psychological) and other valuings pertain to what is, in reality,
good. An “adequate theory of value,” he asserts, “has to be prepared to
take both types of valuings into account” (Rescher 1969:56). “Values”
would thus be used in a psychological sense in the first situation, but in
an ethical sense in the second.
Selecting the definition of “values” that best matches the purpose of
this book—understanding the ethical character of therapy—is no easy
task. Because so many of its uses are non-ethical and because the variety
of definitions is often confusing, I have considered minimizing use of the
term and using words other than “values” to address ethical issues.
Alternatively, I have considered stipulating an ethical use of the term in
this book. But for three reasons, I think it better to use the term in all its
uses, albeit doing so carefully.
First, as noted above, people will continue to use and interpret
“values” in its full range of meanings whatever strategy I employ. And so
it is better to explicitly use “values” in its various meanings and be clear
about my uses of the term in particular situations.
Second, the varying definitions of “values” reflect, and may in part
stem from, unresolved issues in the field of ethics in the West. As Edel
(1988) noted, social scientists picked up uses of the term that originated in
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 97
the philosophical debates of value theory and ethics. Using the term in
ways that make clear its varied meanings makes its linkages to those
philosophical issues more clear.
Finally, different uses of “values” contribute to our understanding of
the ethical dimensions of psychotherapy in different ways. Definitions of
values that are non-ethical can help us learn about the ethical dimensions
of psychotherapy. Understanding “values” as a means by which the
powerful impose their will on the weak, for example, can shed light on
therapists imposing their values on clients, an issue that is clearly ethical
in nature. And, as the following section should make clear, strictly
psychological definitions of values can, when used in empirical
investigations, produce valuable insights into the ethical character of
therapy.
The ethical relevance of psychological research on
values in psychotherapy
D.Rosenthal (1955) pioneered empirical research on the role of values in
therapy. Although employing psychological definitions of values, this
research is relevant to understanding the ethical character of therapy.
Rosenthal found that client values (moral values relevant to psychological
conflicts that are commonly present in therapy) moved in the direction of
therapist values in successful therapy. No such movement was found in
unsuccessful therapy or with nonmoral values.
Subsequent research (Beutler et al. 1994; Consoli and Beutler 1996; T.A.
Kelly 1990; Tjeltveit 1986) has confirmed yet also qualified that finding. It
appears that clients sometimes but not always adopt therapist values,
with the extent of the influence depending on the type of values
measured, the similarity of therapist and client values at the beginning of
therapy, and other factors. This finding, that psychotherapy is not valuefree, raises professional ethical questions about the appropriateness of
therapists converting clients to their own values (Tjeltveit 1986) and gives
credence to neo-Nietzscheans’ suspicions about the role of “values” in the
coercive influence of the powerful on the weak. Furthermore, if clients do
adopt therapist values, therapists need to think clearly about which
values it is best (ideal) for clients to adopt. Or, perhaps, which values they
should adopt.
The empirical finding that therapists sometimes influence client values
(defined psychologically) thus raises issues of values (defined ethically)
that get to the heart of the ethical dimension of psychotherapy.
A related research question addresses the relationship between therapy
outcome and values, including the relationship between therapy outcome
and (1) the initial similarity of therapist values and client values, (2)
particular therapist values, (3) therapist influence on client values, and
(4) client perception of therapist influence on their values. Again,
empirical findings have been mixed. Therapy outcome is apparently
associated with a complex pattern of initial similarity and dissimilarity of
98 ETHICS AND VALUES IN PSYCHOTHERAPY
values. And findings vary with different measurements of values and
with other factors not yet isolated (Beutler and Bergan 1991; Beutler et al.
1994; Consoli and Beutler 1996; Kelly and Strupp 1992). The promise,
however, is to match therapist and client values to improve therapy
outcome.
Although that line of research may appear to be purely empirical, it
also raises important ethical questions. Although rarely thought of in
these terms, “positive therapy outcome,” the good end toward which
therapy aims, is an ethical concept. That is, it is a nonmoral good, or a
“value,” defined ethically. To the extent values (defined psychologically)
enter the therapeutic relationship in ways that produce successful
therapy, then, that nonmoral end, that good outcome, is of great ethical
interest because it pertains to human flourishing, to the good life for
human beings.
Beutler, Machado, and Neufeldt also noted that researchers have
examined the relationship between the values of therapists and clients.
Some substantial differences were uncovered. They noted that, “These
differences, coupled with the potential power that therapists have over
clients, underline the need to evaluate the roles of therapist values on
therapy outcome” (Beutler, Machado, and Neufeldt 1994:240). The ethical
dimension of that “evaluation” would be of great interest to those
concerned about the ethical character of therapy.
Empirical researchers have also examined therapist values, especially
mental health values. Jensen and Bergin (1988) and E.W.Kelly (1995a)
found considerable agreement among therapists concerning values
(defined psychologically) that pertain to mental health and therapy, but
some differences were found in the areas of sex, religion, and
materialistic self-advancement. While those findings do not resolve the
ethical question of which values should pertain to mental health and
therapy (therapists could be mistaken), areas of both value consensus and
value divergence among therapists warrant close attention. Areas of
divergence may be of particular ethical interest, since they may stem from
differences among therapists at the level of underlying ethical theory.
The focus on mental health values by Consoli (1996), Consoli and
Beutler (1996), Jensen and Bergin (1988) and E.W.Kelly (1995a) illustrates
the recent research emphasis on specific values or particular types of
values. Mental health values have been emphasized for two reasons:
therapy more appropriately influences them alone (and not moral or
other types of values) (Hartmann 1960; Strupp 1980) and mental health
values may more likely be influenced in therapy than other types of
values. But distinguishing them conceptually from moral or religious
values has proved difficult. And there is some empirical evidence that
certain types of mental health values vary with certain measures of
religiousness in samples of therapists (Jensen and Bergin 1988) and nontherapists (Tjeltveit et al. 1996). This suggests that differences in values,
even mental health values, may stem from underlying convictions at a
fundamental intellectual level, the level of ethical theory.
UNPACKING DIVERSE UNDERSTANDINGS OF “VALUES” 99
Conclusion
Saying that “a good marriage” is one of Sandra’s “values” can be
interpreted in a wide variety of ways. It is essential that those seeking to
understand the ethical dimensions of therapy select a definition carefully,
in accord with their purposes, and be clear about how they are using it.
And when we understand the various ways in which others use the term,
we can derive greater benefit from the empirical research and other
literature on the role of values in therapy.
But whether we use ethical or non-ethical definitions of “values” to
better understand the ethical character of therapy, the task is very
difficult. Some of this difficulty stems, I think, from differences in ethical
theory that underlie various uses of values. And some of the difficulty
stems from the intellectual and social contexts in which such ethical
inquiry (and all clinical practice) inescapably takes place, contexts that
have shaped (and shape) how we think ethically. It is to those contexts
that I now turn.
Part III
Ethical dimensions of the contexts of
psychotherapy
6
The intellectual contexts of
psychotherapy
Ethics and science
When we think about psychotherapy, we often begin with a fifty-minute
hour. A client and therapist sit down. Taking a deep breath, the client
commences: “Mom and Dad called last night….”
From the typical ways of thinking about such sessions—in supervisory
sessions, case conferences, and quiet, self-reflective moments—rich and
vital understandings of therapy develop. In Chapters 6 and 7 I pursue a
different approach: exploring psychotherapy’s sociohistorical contexts to
see how those contexts have both shaped and obscured the ethical
character of therapy. Orlinsky (1989), MacIntyre (1984), feminist
bioethicists (e.g. Sherwin 1992), and others have stressed the importance
of such contexts in general; Cushman (1992, 1995), Fancher (1995), Hale
(1971, 1995), Kirschner (1996, 1997), Pilgrim and Treacher (1992), and
L.A.Sass (1988) have emphasized the importance of such contexts for
understanding psychotherapy in particular.
I will describe how four different contexts have formed, and form, the
ethical dimensions of psychotherapy. These contexts often influence
therapy in ways that are “so pervasive as to be nearly invisible” (L.A.Sass
1988: 248). I will also try to make more visible what is “nearly invisible”
by suggesting new ways to understand those contexts. For example,
psychology’s positivistic heritage leads some to assume that ethical
reflection is meaningless. And so, desiring to be scientific, many
therapists do not engage in ethical reflection. But alternative
understandings of science, ethics, and their relationship permit the
pursuit of both science and ethics in exploring the ethical character of
therapy.
I will begin with two of psychotherapy’s intellectual contexts—ethics
and science—before turning in Chapter 7 to two of its social contexts—
clinical practice and business. Exploring each context should help us to
gain insight into the ethical aspects of psychotherapy and understand
why it is so difficult for therapists to see, acknowledge, and think about
those aspects. In this chapter, I will first address how key Western values
(defined ethically) make substantive ethical reflection about values
difficult, then I will address psychotherapy’s scientific context.
102 ETHICS AND VALUES IN PSYCHOTHERAPY
The ethical critique of ethics
Observing that ethical standards cause problems for people, some
philosophers, psychotherapy theorists, and psychotherapists have
vigorously challenged those standards. These critiques of ethics are
deeply ironic, however, because they often, and perhaps always, draw
upon ethical sources. They are, in other words, ethical critiques of ethics.
In one type of ethical affirmation, some ways of living are seen as
good, or higher, more good, or better than others. In his brilliant
monograph on the making of the modern identity, Taylor describes how
“basic goods” for which human beings strive, goods like freedom and
altruism, move and motivate human beings. He then documents the
history of how these “basic goods” have driven many of their adherents
to repudiate “all such goods” in the West. And so, continues Taylor,
“they are caught in a strange pragmatic contradiction, whereby the very
goods which move them push them to deny or denature all such goods”
(Taylor 1989’ 88). And that denial of any goodness profoundly challenges
any ethical claim that some ways of living are better (“more good”;
higher) than others.
The Protestant Reformation, argues Taylor, provided a major impetus
to that challenge. Responding to a hierarchical social milieu in which the
“higher calling” of being a priest, monk, or nun was viewed as
qualitatively superior to (“more good” than) other ways of living, the
renegade priest Martin Luther proclaimed the goodness of such
“common” life activities as love and work. He demonstrated this
behaviorally by marrying Katherine von Bora, a nun. Through the
Reformation, the lives of ordinary people were affirmed and seen as
worthy of equal respect with those having allegedly higher religious
callings.
Another important root of the ethical critique of ethics was the
intellectual and political climate in Germany in the nineteenth century, the
climate in which Freud came to intellectual maturity. Moral philosophers
of that era, notes MacIntyre (1966), came to “see the moral as something
they are bound to condemn” (MacIntyre 1966:220).
Nietzsche launched what was probably the most vigorous
philosophical attack on ethical pretensions. Proudly proclaiming himself
“an immoralist,” Nietzsche ridiculed ethical perspectives claimed to be
superior or higher than others. This Nietzschean “leveling” of ethical
positions, of positions that claimed to occupy higher moral ground than
others, is deeply ironic, however: Nietzsche’s challenge was based on
convictions of his own that were deeply ethical (Schacht 1991)’ he valued
especially the creative freedom of the individual to produce produce
transvalued values. This tension in Nietzsche is neatly captured in the
subtitle of Berkowitz’s 1995 work Nietzsche: The Ethics of an Immoralist.
Nietzsche’s attack on morality, reflected in his claim to be an immoralist,
was joined with his ethical vision, which served as a basis both for his
critique of ethics and for his constructive ethical position.
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 103
Nietzschean leveling has been extended to a variety of hierarchical
orderings. The civil rights, feminist, and gay rights movements have
challenged the supposedly “higher” nature of Caucasian heterosexual
males. As noted above, neo-Nietzschean skeptical postmodernists have
pushed the critical side of Nietzsche even further, seeing all ethical claims
to be “imposed order” (Taylor 1989:102). As a result of this ongoing
attack on ethical claims, Joe Klein, in a piece of contemporary cultural
analysis, noted that “it became illiberal…even to make moral judgments”
(Klein 1992:19).
The practice of psychotherapy contrasts sharply with such strong
attacks on ethics; psychotherapists accept some claims to goodness and
reject the opinion that no particular human goal or quality is higher than
any other. They do so because intrinsic to psychotherapy is the conviction
that some ways of living are better than others, are “higher” or “more
good.” A person goes to therapy because they want a better way of living;
the therapist helps the client reach that (good) goal. Psychotherapy thus
assumes that all ways of living are not equal: mental health is better than
mental illness, no symptoms is better than many, adaptive behavior
better than maladaptive, insight than ignorance, authenticity than
inauthenticity, self-actualization better than phoniness, mediocrity, and
suffering.
Cognizant of the problems of attacking all ethical principles, some have
launched a moderated attack on ethics. In contrast to an ethical position
that denies any good and rejects all claims that certain goals are better
than others, this alternative ethical position affirms individual autonomy,
which is seen as the sole human good. Autonomy thus understood is the
good, suggests Taylor (1989), that provides the concealed motivation of
the neo-Nietzscheans. From this basis, all other ethical claims are
attacked, in part because making ethical distinctions has led throughout
history to decreases in freedom. Because the “values” of the powerful or
the majority have too often been imposed on the powerless or the
minority, some passionately propose that, with the one exception of
freedom, we avoid entirely making ethical distinctions, avoid discussing
what is good, ultimately good, right, and virtuous, lest freedom again be
curtailed. The one remaining good: to preserve freedom (or, using
trendier terms, to “liberate” people or be “emancipatory”).
Freedom as the sole good, and the individualism to which it is often
tied, has been subject to severe critique from other ethical perspectives
(e.g. Bellah et al. 1985; Guignon 1993; Sampson 1993; Wallach and
Wallach 1983). Critics have challenged the vagueness of “freedom,” the
failure of users to specify what people are supposed to be free for,
advocates’ unacknowledged, de facto reliance upon richer ethical
traditions (Taylor 1989), and the failure to balance freedom with other
ethical ideals, such as commitment, justice, truthfulness, and community
(Doherty 1995; see Prilleltensky 1997).
Balancing ideals related to therapy will be discussed further in
Chapter 9. My central point here is that philosophers have critiqued all
ethical reflection, often doing so on the basis of covert ethical stances.
104 ETHICS AND VALUES IN PSYCHOTHERAPY
These ethical critiques of ethics warrant careful attention: some ethical
positions are indeed problematic. But the duplicity of the claim to be
ethically neutral, to be without ethical sources, deserves challenge. A
more accurate picture of the current reality is this: the critiques of ethics are
not value-free; rather, different ethical positions are competing with one
another to determine which is best.
Psychotherapy theorists have created their own variants of the ethical
critique of ethics. They describe how making ethical distinctions and
judgments leads to emotional disturbance, or is evidence of a lack of
mental health. Freud, for example, functioned at times as an unabashed
moral critic. Wallace points out that Freud was “positively acerbic toward
the ‘golden rule’”, for example, claiming it “was not only psychologically
unworkable and maladaptive for the individual, but that it cheapened the
love for family and friends” (Wallace 1986:99, 100). Indeed, “as early as
1900 Freud was using psychogenetics as an instrument to demolish
man’s moral pretensions” (ibid.: 90). But Freud’s was a balanced ethical
critique, for he realized the importance to civilization of moral rules and
self-restraint (Wallace 1986; Wallach and Wallach 1983) and saw the
suspension of moral rules in psychoanalysis as a temporary expedient to
help clients develop insight and make positive changes. Neo-Freudians
such as Wilhelm Reich (Wallace 1986), Erich Fromm, and Karen Horney
(Wallach and Wallach 1983), however, viewed moral injunctions in more
consistently negative terms. Horney’s (1950) memorable phrase, “the
tyranny of shoulds,” for instance, emphasizes the inexorably maladaptive
consequences of ethical principles in the life of the neurotic, admitting no
positive role for them.
For Carl Rogers, ethical standards become “conditions of worth” that
prevent persons from functioning fully. And so he asserted that healthy
clients move “away from ‘oughts’” (Rogers 1961:168), basing that claim,
of course, on his ideas about “the good life.”
And Ellis regularly addresses ethics in negative terms such as
“absolutistic, dogmatic shoulds, oughts, and musts” (Ellis 1987a:121).
High moral standards are irrational and cause emotional disturbance.
Ellis critiques all strong ethical convictions. He lumps together silly
“shoulds” (e.g. “I should be able to make my partner deliriously happy at
all times”) and more substantive shoulds (e.g. the repeated incest
offender’s, “I should not rape my 6-year-old niece”). He then critiques all
strongly held “shoulds” as absolutistic and irrational. The source of his
critique: his deeply held ethical convictions about the best (“most
rational”) way for human beings to live. Similarly, Burns lists “SHOULD
STATEMENTS” as a type of cognitive distortion (Burns 1980:40). In the
hands of clients, of course, such attacks on “shoulds” are often translated
into the self-contradictory, “Oh, that’s right. I shouldn’t use ‘shoulds.’”
Because of this therapeutic/ethical critique of ethics, Doherty
concluded that, when “egocentric therapeutic morality” is at work,
“every expression of obligation is unhealthy until proven otherwise”
(Doherty 1995:29). And Bellah, Madsen, Sullivan, Swidler, and Tipton
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 105
note that “the therapeutic view…not only refuses to take a moral stand, it
actively distrusts ‘morality’” (Bellah et al. 1985:129).
But it is far easier to identify this therapeutic animus against morality
than to recognize its ethical origin. One source: the aspiration of most
therapists to be value-free. As Beutler notes:
Our mentors have implied, if not overtly said, that if it only were
possible surgically to remove the therapist’s values, he or she would
be a more effective clinician. In the greatest of therapeutic
paradoxes, a valueless clinician is valued.
(Beutler 1989:4)
Therapists who make ethical assertions while aspiring to such valuefreedom must therefore hide their ethical stances. And, when critiquing
the ethical positions of others, they must disguise the ethical bases of
those critiques. At times this deception is intentional; more often, I
suspect, therapists’ ethical stances become hidden even to themselves.
Many therapists who have never read the philosophers just discussed,
or who do not share all the views of those therapy theoreticians, share
their deep suspicion of ethics. They have no special need for the
observations of those philosophers and theorists: the victims of overly
harsh and rigid moral standards come daily to therapy, seeking
assistance for problems often made worse, at least in part, by their own
moral standards. Clients’ deontic words, “obligation,” “ought,” and
“duty,” produce human pain, and so therapists sometimes flinch at the
thought of using them. The human cost seems too high. An elegant
solution to eliminating a client’s pain appears evident: eliminate the
“shoulds” that cause the pain.
But it is not just the deontic moral “shoulds” that seem troublesome.
Any ideal, any notion of human flourishing, any concept of virtue can
produce pain in clients. For if a focus on obligation can produce guilt, a
focus on flaws of character or virtue can produce shame (Fossum and
Mason 1986; G.Kaufman 1992, 1996). Both duty and virtue, both deontic
and aretaic judgments, thus seem objectionable: they harm people.
This ethical critique of ethics stems from a fundamental moral
conviction, “we should avoid harm,” and its corollary, “all that causes
harm is to be eschewed.” Although some therapists acknowledge that
ethics is in some sense valid, and that harm stems from misuses or
psychopathological distortions of ethics, many see ethics itself as the cause
of client problems. The practical effect of the belief that ethics harms
people is that ethical convictions—of clients and therapists—are pushed
underground.
The ethical convictions underlying the belief that it is good to minimize
harm are complex, however, because one person’s harm is another’s
benefit. Some see increased assertiveness, for example, as boon, but
others as bane. Likewise with loss of religious faith. This is because an
106 ETHICS AND VALUES IN PSYCHOTHERAPY
understanding of what is harmful rests on some broad ethical vision of
what is good and right: harm is what deprives a person of what is good
or right. In the absence of consensus about what is good and right, there
will not be agreement about what is harmful.
Taylor (1989) suggests that four fundamental moral ideas are central to
the modern identity: reducing suffering, freedom, equality, and universal
justice. The first three have been used—by philosophers, psychotherapy
theorists, and therapists—to critique particular ethical positions and
some problematic ways people use ethics. Those ideas have therefore
contributed to a decline in explicit ethical reflection in the West, though
they have not led to the absence of ideas about what is good, right, or
virtuous, of ideas that guide behavior and shape character, of ideas used
to critique ethics.
The problems identified by the ethical critique of ethics are real: ethics
has been used to harm people and to deprive them of freedom and
equality. Some conclude that ethics should therefore be rejected. But an
alternative is readily available: uses of ethics that do not harm people or
deprive them of freedom and equality. Critiques of ethics can be very
valuable. But they will become more valuable when the ethical
convictions used to critique ethics and inform psychotherapy, convictions
now largely implicit, become explicit.
The scientific context
“Psychotherapy should be based on science.” That pivotal assumption
(along with other aspects of the scientific context of psychotherapy)
shapes the ethical dimensions of psychotherapy, yet also obscures them.
Psychologists (Freedheim 1992; Routh 1994), psychiatrists (cf. Karasu
1980), and other mental health professionals (Talley et al. 1994) have long
aspired to base the practice of psychotherapy on science (e.g. Gesell et al.
1919). Indeed, McFall asserted that “there is only one legitimate form of
clinical psychology: grounded in science, practiced by scientists, and held
accountable to the rigorous standards of scientific evidence” (McFall 1991:
79; see Sechrest 1992; Hayes et al. 1995; Meehl 1997).
Such strong assertions about the proper relationship between science
and practice generate spirited attack and passionate defense (see Kazdin
1996). But I want to focus here, not on that broader debate, but on the
relevance of science, and the scientific context, for the ethical dimensions
of therapy.
“Science answers scientific questions, but not those that are ethical”
some assert, “because science is an objective, objective, ‘value-free,’
ethically neutral endeavor.” Others claim that science does contribute to
ethics by uncovering ethically relevant facts. I address that dispute in this
section, considering whether, or in what ways, science, and certain ways
of thinking about science, contribute to the ethical dimensions of therapy.
But a second issue must also be addressed. Because I believe that
science, appropriately conducted and understood, does contribute in very
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 107
important ways to the ethical dimensions of therapy (and to our
understanding of them), I will turn in the last part of the chapter to this
question: to understand well the ethical dimensions of psychotherapy,
should we rely upon science alone, or upon science in conjunction with
ethics?
Science’s contribution to the ethical dimensions of
psychotherapy
I want to begin by reviewing briefly some history that bears directly on
the relevance of science for the ethical dimensions of therapy. But first, a
caveat: as Kendler noted, “the relationship between psychology and
ethics depends on the societal meaning that is assigned to each term”
(Kendler 1993: 1046). And so all arguments, including mine, depend on
the meanings given to those terms. People holding understandings of
science and ethics different from those outlined in earlier chapters will no
doubt understand their relationship differently (cf. Kitcher 1985; Midgley
1978; Singer 1981; Wright 1994).
Those who first taught psychology courses in the US would have
thought it very odd to question the contribution of psychology,
understood as science, to ethics. Odd for two reasons: psychology was not
then a science (in the contemporary sense of the word), and psychology
was part of ethics.
Mental philosophy, moral philosophy, and moral science were the
branches of knowledge to which psychology first belonged (Evans 1984;
Leahey 1997). As such, psychology courses were first offered in the US,
most likely in 1840 at Marshall College (later Franklin and Marshall
College) (Evans 1984), long before the “New Psychology” of Wundt,
James, and Hall (see Fay 1939; G.S.Hall 1894).
“Old Psychology” was introduced into the college curriculum in the
1800s because American colleges sought to shape the character and
ethical ideals of their students. And the discipline of psychology “aimed
to inculcate moral virtues” (Sexton 1978:3). In the typical pattern, a
college’s curriculum culminated in a wide-ranging course in moral and
mental philosophy taught to seniors, usually by the college president,
who was generally a clergyman (Bryson 1932; G.S.Hall 1894; Ross 1979;
Schmidt 1930). The substantial psychological content in these courses was
integral to their ethical intent. In his 1870 Lectures on Moral Science, the
president of Williams College, Mark Hopkins, succinctly articulated the
importance of psychology:
What man ought to do will depend on what he is, and the
circumstances in which he is placed. Mental science, or psychology,
will therefore, be conditioned [that is, be foundational] for moral
science…The province of psychology will…be to show what the
108 ETHICS AND VALUES IN PSYCHOTHERAPY
faculties are; that of moral philosophy to show how they are to be
used for the attainment of their end.
(cited in Evans 1984:43)
And so, Leahey notes, for the Old Psychologists, “psychology was the
gateway to moral knowledge and the mainspring of moral action”
(Leahey 1987b:12).
But with the transition from Old Psychology to New Psychology,
psychologists sought disciplinary independence, rejected philosophical
methods (and sometimes all of philosophy), and strove to be objective
scientists. And so psychology and ethics divorced.
New Psychologists wanted, for a variety of reasons (O’Donnell 1985;
Ross 1979), to establish psychology as an independent discipline (Bellah
et al. 1983) and, especially, as a scientific discipline. Leahey (1987b) notes
that whereas Old Psychology saw itself as subordinate to ethics,
“deserving study not as an end in itself but as a means to the greater end
of morality,” New Psychology “wanted to establish its science as a
valuable end in itself” (Leahey 1987b:12). Many psychologists assumed
this independence required severing their ties with philosophy (Camfield
1973).
Indeed, “anti-philosophical rhetoric,” Toulmin and Leary note, “came
to typify behavioral psychology in the United States” (Toulmin and Leary
1992:600). And so Sexton observes, “terms like philosopher and
philosophy became terms of opprobrium” (Sexton 1978:6). And this antiphilosophical tenor was not limited to academic psychology. Lightner
Witmer, the founder of clinical psychology, claimed his approach “was a
protest against philosophical speculations” (Reisman 1976:48).
But declaring independence from its philosophical parent was not the
only reason psychologists moved away from addressing ethical issues.
The growing specialization characteristic of the late nineteenth century
(Higham 1979) also played a role. Any attempts to address ethical issues
(such as those involved in psychotherapy) would, psychologists feared,
dilute and confuse the identity of the nascent discipline.
The scientific aspiration to achieve objectivity and ethical neutrality, to
become “value-free” (Leary 1980; Robinson 1981), was another reason
psychologists stopped addressing ethical issues. That is, they assumed
that, when investigating a topic, including an ethical topic, a psychologist
qua scientist ought to remain neutral (Ross 1979). Consequently, New
Psychologists “proudly cast off moral, especially religious, values in the
name of science” (Leahey 1987a:361). Again, academicians were joined by
clinicians who aspired to ethical neutrality. Freud, for example, “took
pains to keep clinical apart from moral evaluation” (Hartmann 1960:17).
Psychologists’ embrace of logical positivism further distanced them
from overt, conscious ethical reflection: ethical assertions were now
either regarded as meaningless or redefined. Consider this excerpt from a
poem:
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 109
A thought
Is surely neither bad nor wrong
Or right or good?
No, no.
Define
and thus expunge
The ought,
The should!
…
Truth’s to be sought
In Does and Doesn’t.
(Skinner 1972:348–9)
Lest there be any doubt about its meaning, B.F.Skinner exegeted his poem:
“But what about the possibility that [a thought] might be right or good?
No, logical positivism will take care of that. By defining our values we
expunge them.”
Although the logical positivist philosophy of science has fallen out of
favor, many still assume the truth of its ethical claim: ethical assertions are
cognitively meaningless. Other scholars, indifferent to that philosophical
debate, focus on producing scientific knowledge. They seek facts, not
values (defined ethically), from science. As Karasu noted:
Science and ethics have been viewed as two distinct and separate
entities, almost antithetical: science as descriptive, ethics as
prescriptive; science as resting on validation, ethics as relying on
judgment; and science as concerned solely with “what is,” ethics as
addressing “what ought to be.”
(Karasu 1980:1502)
And so the resistance to ethical reflection among scientifically oriented
practitioners is powerfully overdetermined: psychology’s desire to be an
independent discipline, scientists rejecting the philosophical methods
employed in ethics, the logical positivist doctrine that ethical assertions
are meaningless, the desire to be objective, and a sole focus on scientific
knowledge (interpreted as ethically neutral) all keep psychotherapists
from overtly and consciously addressing ethical issues.
But this avoidance of explicitly ethical reflection is deeply problematic,
because practitioners cannot avoid addressing ethical issues in
psychotherapy. One solution to this problem is to turn to science for
answers to ethical questions. And, indeed, despite the many reasons for
avoiding ethical reflection and sharply distinguishing science and ethics,
some nevertheless maintain that scientific findings can contribute to
ethics. That is, some philosophers and some psychologists insist that:
110 ETHICS AND VALUES IN PSYCHOTHERAPY
Although psychology is appropriately distinguished from ethics,
psychotherapy’s scientific context can shed light on the ethical
dimensions of therapy. Old Psychologists were partly right: an
adequate ethics requires an adequate knowledge of human beings.
Since psychology’s scientific methods produce such knowledge,
science contributes to ethics.
Suppose that we are asked to evaluate the ethical dimensions of Dr
Johnson’s newly invented “Neo-Cognitive Therapy.” Ethical questions
we might address include: is it a “good” treatment? Is there anything
“wrong” with it? Which ethical characteristics (“virtues”) does it tend to
produce in clients?
Science will be relevant to those ethical questions to the extent it
produces facts pertinent to an ethical evaluation of “Neo-Cognitive
Therapy.” As Frankena asserts, “moral philosophers cannot insist too
much on the importance of factual knowledge…for the solution of moral
and social problems” (Frankena 1973:13). If a carefully designed empirical
study determines, for instance, that Neo-Cognitive Therapy does not
reduce psychological symptoms or otherwise help clients reach the goals
Dr Johnson claims for it, it is not a “good” therapy. If it consistently
harms clients, it is wrong for therapists to use it with clients. And a client
choosing between that and alternative therapies would find quite relevant
facts about the effectiveness (and thus “goodness”) of those treatments
(Roth and Fonagy 1996; Nathan and Gorman 1998). And so, “description
can inform prescription” (Faust and Meehl 1992:203).
Waterman (1988) argues that scientists can contribute to ethical
reflection in two ways. First, science can help evaluate claims about
human nature that are relevant to ethics. For instance, Waterman
adduces empirical evidence that supports the assumptions Rawls (1971)
made about human nature in his theory of justice. B.Schwartz (1990)
warns, however, that a scientific study of “human nature” (e.g. of human
values) may, in fact, be the study of human behavior in a given
sociohistorical context, but nothing more. And so we must exercise caution
when tempted to draw universally applicable ethical conclusions from a
“human nature” so transitory and culturally specific.
Second, Waterman asserts that scientists can evaluate the empirical
claims contained in teleological (or consequentialist) normative theories.
As discussed in Chapter 4, those theories maintain that we can best
answer ethical questions by focusing on the telos (“end”) of an act, that is,
on its consequences. For instance, “It is unethical for therapists to engage
in sexual relations with their clients because doing so consistently
produces negative consequences: psychologically damaged clients.”
Science is relevant to such theories because empirical investigations
promise to tell us whether purported consequences actually follow from
such acts. If they do, such acts are unethical.
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 111
On the basis of such a teleological ethical theory, Imber, Glanz, Elkin,
Sotsky, Boyer, and Leber (1986) asserted that “significant positive ethical
values” (defined ethically) “derive from” the findings of the US National
Institute of Mental Health collaborative study of treatments for
depression. Likewise, Beutler and Harwood’s claim that “empirical
research should form the basis for selecting and implementing treatment”
(Beutler and Harwood 1995:89, emphasis added) rests upon a
consequentialist ethical theory and scientific findings to draw its ethical
conclusions. If measurable positive outcome is the end to which
psychotherapy aims, we should be able, in principle, to determine
empirically which form of therapy is best, or “most good.” And so, other
things being equal, we can determine which form of therapy we should
pursue.
And so, despite a scientific context that has contributed to
psychotherapists’ overdetermined avoidance of ethical issues and desire
to distinguish sharply between science and ethics, scientific findings are
relevant to some ethical questions, for the reasons just discussed: the
consequences of an action are often ethically relevant. And science
provides us with knowledge about consequences, knowledge about
which we can be reasonably confident. Science thus contributes to ethics.
Understanding psychotherapy’s ethical dimensions:
“science alone” or “science and ethics”
Because science can help us to address ethical issues, it is possible to
make the further claim that we can, or even ought to, rely on science alone
to address ethical questions. In this section, I want to examine that claim,
along with the claims of those who acknowledge science’s contributions
to addressing such ethical questions but argue that we also need to use
other methods, methods from ethics.
Suppose we are confronted with an ethical issue such as which therapy
goal is best (“most good”) for a given client, which virtues a good
therapist possesses, or what obligations therapists owe their clients. Some
say science alone will provide whatever meaningful answers we can
obtain. Others eagerly draw upon relevant empirical findings, but also
take full advantage of relevant ideas, methods, and principles from
professional ethics, philosophical ethics, clinical ethics, virtue ethics,
social ethics, and cultural ethics, including approaches (discussed in
Chapter 4) that obtain ethical knowledge through tradition, through
reason, through an explicit combination of reason and nature, through
such extra-rational personal qualities as intuition or choice, through
divine revelation, through relationships (including communities), or
through the interpretation of narratives (e.g. in hermeneutic approaches).
That is, they argue that we best answer ethical questions with a
combination of science and ethics. And they thus argue that
psychotherapy (as an inescapably ethical activity) should be based, not
only on science, but also on ethics.
112 ETHICS AND VALUES IN PSYCHOTHERAPY
The scientific context of psychotherapy thus gives rise to an important
dispute: how to best address ethical issues in psychotherapy. How we
resolve that dispute has important implications for how we understand
therapy, how we educate therapists, and how we think about the ideal
role of therapy in society.
Science alone
Psychotherapists who strive to rely on science alone to address ethical
issues can do so in several distinguishable ways. All are variants of
“scientism,” defined by Taylor as “the belief that the methods and
procedures of natural science…suffice to establish all the truths we need
to believe” (Taylor 1989: 404). Two varieties can be distinguished:
philosophical scientism (the philosophy that scientific methods are the
best or only way to obtain all varieties of truth, save those of logic and
mathematics) and de facto scientism (referring to those who are, in fact,
guided only by science, although they do not espouse philosophical
scientism).
A bold doctrine, philosophical scientism at times extends the proper
realm of science from its customary objects of inquiry (e.g. physical,
biological, social, and psychological topics) to the realm of ethics (thus
answering the questions posed by the German value theorists).
Psychotherapists aspiring to be scientific have been among the devotees
of this doctrine. As Doherty noted, “A cornerstone of all the mainstream
models of psychotherapy since Freud has been the substitution of
scientific and clinical ideas for moral ideas” (Doherty 1995:9). Advocates
claim the methods of science can be applied fruitfully to all topics. Indeed,
McFall (1991) claimed it is possible for psychological scientists to use the
same “objective” evaluations they use to determine what is “good
science” to judge clinical activities.
Proponents provide a variety of arguments to justify expanding the
range of science to include ethical issues. Some claim to derive ethical
assertions (understood in a traditional way) from science alone; others
redefine what has traditionally been labeled ethical (scientific methods
are then used to investigate the redefined “ethical” phenomenon); still
others (perhaps most) do both.
The attempt to build ethics on a scientific foundation is not new.
J.B.Watson (1924), “considered behaviorism a foundation for all future
experimental ethics” (Dukes 1955:24). And Clark Hull argued that
questions of moral behavior (Ash 1992) and value (Hull 1944) could be
addressed through empirical methods. Cattell ambitiously titled his 1972
book A New Morality From Science. And Nagy claimed an “empirical
basis” as “the foundation” of the revision of the American Psychological
Associations code of ethics (Nagy 1994:505). As is typical, no other basis
for the code was mentioned.
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 113
Another important strand of philosophical scientism is associated with
the ethical theory held by logical positivists (cf. Proctor 1991). As
discussed above, logical positivists held that traditional ethical assertions
are not cognitively meaningful because they are not based on science. The
philosophical scientism associated (but not identical) with logical
positivism redefines “ethical” issues before asserting that science alone
provides us with knowledge of them. If, for instance, ethical assertions
refer, not to what is good or right, but solely to feelings about goodness
and rightness, those feelings can be investigated empirically in the way
all other emotions are investigated.
In contrast to “expansionists” (Graham 1981) who espouse
philosophical scientism and advocate expanding the role of science to
embrace ethics, those who exhibit de facto scientism aspire to restrict the
range of science or make modest claims for science. Nevertheless, since
they restrict their attention to scientific findings, they end up being
influenced only by science when they address ethical issues.
Those exemplifying de facto scientism can be divided into two groups:
ethical agnostics and the single-mindedly scientific. Ethical agnostics
believe that a scientist qua scientist ought not, in principle, to address
ethical issues. As Parloff noted:
many, following the precedent of Freud, disclaim interest in
influencing the values of patients, on the basis that as scientists they
are concerned with reality and facts and do not presume to be in a
position to provide the patient with a philosophy of life.
(Parloff 1967:14)
Believing ethical issues to be beyond the scope of their discipline, they
remain undecided. Believing in a strict separation between science and
ethics, they may set aside or “bracket” all ethical issues (Drane 1982,
1991; Dukes 1955).
Another source of ethical agnosticism is applying the intellectual habits
learned as scientists to ethical matters. Barlow, for instance, asserts that
“one of the principal virtues of a good scientist is skepticism” (Barlow
1996: 236). When skepticism is applied to ethical matters (where
considerably less certainty is possible than in the realm of traditional
scientific topics), ethical skepticism may be the result. Similarly, when the
principle of parsimony is applied to a situation in which ethical issues are
intermingled with scientific issues (as they often are, for example in the
ethical dimensions in psychotherapy), explanations tend to be restricted
to the scientific dimension of the problem. To keep matters simple, the
investigator may ignore, or remain agnostic about, the problem’s ethical
dimension.
Those who are single-mindedly scientific, in contrast both to those
advocating philosophical scientism and to ethical agnostics, have no
interest in broader theoretical issues. They devote their lives to reading,
designing, conducting, and writing-up experiments. Their theorizing
114 ETHICS AND VALUES IN PSYCHOTHERAPY
extends at most to scientific micro-theories. They have neither time nor
desire, neither the training nor the inclination, to engage in ethical
reflection. They know or like science best, or science is all they know.
But when faced with ethical issues, both ethical agnostics and the
single-mindedly scientific appear to draw solely upon what they know—
science—to address those ethical issues. Although their philosophical
convictions do not mandate that science should play such a role, science
alone informs their ethical convictions. The result: de facto scientism.
The major claim of scientism relevant to this discussion—that we can
rely on science alone to address ethical issues—rests, at least in its
strongest philosophical form, on the following:
The methods and assumptions of science must be sharply
distinguished from those of ethics. Strictly objective and driven
entirely by data, scientists properly employing the scientific method
can be ethically neutral and value-free. Therefore, they need not
draw upon the discipline of ethics in any way to answer the ethical
questions ethics traditionally addressed.
Those convictions are important because if ethics is intermingled in some
way with science, any conclusions supposedly drawn from science alone
derive, in fact, from both science and ethics, not from science alone.1
Three types of challenge face the claim that we need science alone to
answer ethical questions: (1) certain values (defined ethically) are
intrinsic to the scientific endeavor; (2) certain ethical convictions (not
intrinsic to science) do, in fact, enter into psychological research,
whatever the researchers’ aspirations to ethical neutrality; and (3)
science, although essential to ethical endeavors, cannot fully address
ethical issues. I will address each challenge in turn.
I should first note, however, that even if the first two challenges are
accepted, modified forms of the “Science only” claim can be espoused: (a)
“We can rely on science alone (science being ethically neutral in the main,
with the exception of those few and inconsequential values that are
intrinsic to science) to address ethical issues”; and (b) “Ethical convictions
not intrinsic to science can be present in the early stages of a research
program, but will eventually be weeded out as hypotheses are subjected
to empirical test.”
Values intrinsic to science
Philosophers of science, ethicists, and theoretical psychologists (Graham
1981; Haan et al. 1983; Laudan 1984; Longino 1990; Proctor 1991; Riley
1974; Stevenson and Byerly 1995; Thackray and Mendelsohn 1974;
Waterman 1988) no longer find plausible the claim that science (even
when properly conducted) can be, or should be, entirely free of values
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 115
(defined ethically). Certain values (ethical assertions of a particular type)
appear to be intrinsic to the scientific endeavor.
Controversy has developed, however, over the specific values science
supposedly requires and the extent to which they permeate it. Howard
(1985) argued that science requires “epistemic values.” In describing the
standards scientists use, he set forth the following values associated with
science: predictive accuracy, internal coherence, consistency with other
theories, unifying power, fertility, and simplicity. (I refer to these as
ethical values because, for instance, it is considered good for a scientist to
predict accurately. Most of the values considered intrinsic to science are
nonmoral ethical values, with the exception of honesty: Scientists who lie
about their results are considered immoral or unethical.) Cournand
(1977) points to the scientific values of honesty, objectivity, tolerance,
doubt of certitude, and unselfish engagement. Hofstadter and Metzger
(1955) list tolerance, honesty, publicity, testifiability, individuality, and
cooperativeness. In Rokeach’s (1979) empirical investigation of values
associated with science (employing five methods), the highest rankings
were given to the terminal values of wisdom, freedom, self-respect, and a
sense of accomplishment, and to these instrumental values: intellectual,
capable, honest, and responsible. And Popper (1962/1976) adds to truth,
“our decisive scientific value,” the values of relevance, interest,
significance, fruitfulness, explanatory power, simplicity, and precision.
Popper distinguishes between “purely scientific values” (similar to
Howard’s 1985 “epistemic” and Laudan’s 1984 “cognitive” values) and
“extra-scientific values,” such as human welfare (Popper 1976:97). He
stresses that scientists ought not to confuse the two.
But Toulmin (1975) argues that two ethical stances have historically
characterized scientists: the Newtonian and the Baconian, reflecting the
emphases of Newton and Bacon. The first stance sees the purpose of
science to be strictly intellectual, to obtain truth about nature; the second
sees the purpose of science to be human welfare (cf. Hofstadter and
Metzger 1955). He suggests that with colleagues, scientists stress the
Newtonian, but with funding agencies the Baconian.
Popper argues for the Newtonian morality of science, relegating the
Baconian to the status of “extra-scientific.” Although the existence of the
American Psychological Society (APS) stems from a desire to strengthen
scientific psychology (their emphasis is clearly on Newtonian morality),
the wording of its statement of purpose, “to promote, protect, and
advance the interests of scientifically-oriented psychology in research,
application, and the improvement of human welfare” (APS 1988:1, emphasis
added), makes it evident that a Baconian element is present in the
scientific morality of the APS as well. This is also true of the American
Psychological Association (APA). Its statement of purpose includes both
the Newtonian goal of advancing psychology “as a science” and the
Baconian goal of “promoting human welfare” (APA 1994:1).
Rejecting both Baconian and Newtonian moralities, Skolimowski
(1975) argues for a third morality of science: the Copernican. Copernicus
116 ETHICS AND VALUES IN PSYCHOTHERAPY
wanted an intellectual understanding that would include the physical,
the moral, and the aesthetic orders. In calling for “a broader conception
of science which will be based on a broader conception of knowledge or
on the unification of the cognitive with the normative,” Skolimowski
(1975:134) joins others (e.g. Braybrooke 1987; Haan et al. 1983; Keat 1981;
E.V.Sullivan 1984) who address the need for a new philosophy of the
social sciences that will tie ethical considerations more closely and
explicitly to the social sciences.
A consensus that science is value-laden thus coexists with deep
disagreement about which values (defined ethically) are intrinsic to
science. Kendler’s (1993) observation, that any account of the relationship
between psychology and ethics will depend on how each term is defined,
is clearly relevant here. But the disagreement is more fundamental than
definitional disagreement. Deep differences about the nature of science
and about ethics are manifest.
What is evident is that science and ethics are deeply intertwined. And
that separating them crisply is neither possible nor desirable.
The presence in the heart of science of essential ethical principles
requires intellectual justification. Reasons must be provided for claims
that these values are good, that one is most important, and that they
merit our allegiance. That is a task for which ethics is well suited, but
science not. Indeed, noted philosopher of science Larry Laudan argued
that we need a systematic way to evaluate ethically the goals of scientific
inquiry, an “axiology of inquiry” because “methodology gets nowhere
without axiology” (Laudan 1987:29).
To summarize, when science produces ethical knowledge, ethical
assumptions essential to science play a role in producing that ethical
knowledge. Science and ethics thus both play a role. The scientific
context thus shapes the ethical character of psychotherapy and our
understanding of it through a combination of the scientific method, data,
and ethical convictions intrinsic to science. A value-laden science
contributes values (defined ethically) to therapists. But “the fact,” as
Laudan observed, “that the axiology of inquiry is a grossly
underdeveloped part of epistemology and philosophy of science”
(Laudan 1987:29) points to one way in which the scientific context, by
neglecting the ethical component of science, has obscured the ethical
character of science, and, by extension, of psychotherapy.
Advocates of scientism have, as noted above, a ready response to this
first challenge to the claim that science alone can produce ethical
knowledge: science is inconsequentially value-laden. We can rely on
science alone (science being ethically neutral in the main, with the
exception of those few values that are intrinsic to science) to address
ethical issues. We can focus on Popper’s (1962/1976) scientific values, and
strive to expunge from science all extra-scientific values.
This proposal faces at least two problems. First, as noted, deep divisions
about which values warrant the honorific label “scientific” exist. Indeed,
Popper considered “extra-scientific” certain values which several of the
authors cited regard to be essential to science. Second, as Popper
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 117
observed, “it is practically impossible to achieve the elimination of extrascientific values from scientific activity” (Popper 1976:97). This is
particularly likely when scientists investigate morality (Kurtines et al.
1990). Waterman concurs, warning that “when psychologists design
studies of morality, they are very likely guided by their own moral
preferences” (Waterman 1988: 296).
By way of contrast, Kendler (1992) argues that impartial research can
be conducted on sensitive topics. And Rokeach (1973) claimed to be able
to conduct value-free research on values.
One way to address the role of extra-scientific values (however defined)
in science is to review briefly investigations of their role in scientific
research. It is to that task, addressing the second challenge to the claim
that ethical conclusions can be based solely on science, that I now turn.
Extra-scientific values
To discover the influence on science of “extra-scientific” ethical
convictions, some scholars have examined researchers’ autobiographies.
Leary did so, discovering a clear “heritage of moral concern” in both preWundtian scholars and modern psychologists (Leary 1980:283). Although
the valuefree ideal kept the moral concerns of the latter from appearing in
their published psychological writings, Leary found that many
prominent psychologists “are still extremely concerned about changing
the human world for the better” (ibid.: 300). For instance, the personal
memoirs of central figures in animal-learning theory (Edward C.Tolman,
Clark Hull, and B.F.Skinner) make clear their concern to benefit others.
Kendler (1989) points to Kurt Lewin, for whom Nazism and his failure to
rescue his mother from a Nazi concentration camp led to a concern for
applied ethics through his program of action research.
Morawski (1982) did another type of uncovering. Examining the
Utopian visions in the writings of early psychologists G.Stanley Hall,
William McDougall, Hugo Munsterberg, and John B.Watson, she found
“programs for societal improvement” both in their Utopian and their
professional writings (Morawski 1982:1082). Skinner contributed his own
Utopian vision in Walden Two (1948), articulating an underlying ethical
theory involving the ultimate good of survival (Leahey 1987b) or an ethic
of justice (D.S.Browning 1987).
Steininger (1979) and Leahey (1987b) also documented how
psychologists, striving to be value-free, have in fact made ethical
assertions and relied on operative ethical theories. McLure and Tyler
(1967) discussed how researchers investigating values draw upon their
own values in doing so. Hence, although they have done so in different
ways (Leary 1980), many psychologists have pursued ethical aims, extrascientific ethical aims, in their research.
But perhaps the most important moral convictions surreptitiously
wedded to science are those linked to scientism, the view that science
118 ETHICS AND VALUES IN PSYCHOTHERAPY
alone provides the truths we need (with the exception of those derived
from mathematics and logic). In his careful historical review of the
making of the modern identity, Taylor notes that there were not
“conclusive reasons” for adopting the belief that natural science provides
us with all the knowledge we need. Adopting the creed of scientism was,
instead, “a leap of faith” powered by “a moral vision”: “one ought not to
believe what one has insufficient evidence for” (Taylor 1989:404). I doubt
that any ethical convictions in the scientific context of psychotherapy
have been of greater importance for our understanding (or lack thereof) of
the ethical dimensions of psychotherapy.
But devotees of scientism, under conviction that science alone provides
us with knowledge about ethical matters, have a ready response to the
presence of extra-scientific values in science: ethical convictions not
intrinsic to science can be present in the early stages of a research
program, but will eventually be weeded out as hypotheses are subjected
to empirical test. Sometimes relying upon the positivist distinction (Leary
1980) between the context of discovery (where extra-scientific convictions
are valid) and the context of justification (where they are not), they often
hold that extrascientific values “are gradually sifted out” (Kurtines et al.
1990:283) as researchers pursue values that are intrinsic to science.
Some of the concerns of advocates of scientism are legitimate, albeit
not limited to those holding their ethical views. Mixing ethical or political
convictions with science can be dangerous (Proctor 1991), with the former
Soviet Union’s insistence upon Lamarckian biology being perhaps the
most vivid example. Furthermore, I agree that ethical assumptions
present in the early stages of a research program (in its context of
discovery) should change over the course of an investigation if clear and
convincing evidence is discovered that conflicts with them. For example,
a researcher convinced abortion is wrong for one reason—its harmful
consequences to women (the “postabortion syndrome”)—appropriately
drops that ethical conviction if the existence of such a syndrome cannot
be established empirically. Or the reverse. Finally, I think science is an
uncommonly good way to answer a number of important questions, and
so I share (in moderate form) the views of those who want to rely upon it
whenever it is applicable.
But ethics can aid even those scientists who operate with traditional
understandings of science by helping to identify implicit ethical
convictions in scientific inquiries.
The authors cited above, however, claim that completely eradicating
extra-scientific values from science is impossible. Continuing to insist
that ethical convictions be severed from “good” scientific work may
serve, not to eliminate such ethical convictions, but to make them
invisible to scientists and those who consume research. Accordingly,
scientists should make their extra-scientific values explicit, in accord with
science’s values of openness and accountability to peers.
In any case, to the extent that ethical convictions are present in the
practice of science, whether values intrinsic to science or extra-scientific
values, science itself may benefit from a careful ethical analysis of the role
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 119
of such ethical convictions in science. That is, Laudan’s (1987) call for an
“axiology of inquiry” applies not only to values intrinsic to science but
also to extrascientific values, whether those extra-scientific values reflect
researchers’ personal convictions or ethical assumptions contained within
psychological theories.
Advocates of scientism may find Laudan’s proposal unconvincing
because it conflicts with their moral convictions that one ought not
believe in anything, including axiology, for which there is no solid
scientific evidence. Their claim, of course, is decidedly paradoxical: their
ethical convictions ban ethical convictions. But because I believe it valid
to hold ethical convictions, I think advocates of scientism can enter the
ethical debate about the relationship of science and ethics. Indeed, they
must. Because their ethical convictions have powerfully shaped, and
obscured, the ethical character of therapy: obscured it because, if therapy
is to be based on science alone and the scientist ought not to turn to ethics
to address ethical questions, values intrinsic to science are given no voice,
indeed, they are banished.
The ethical claims of scientism therefore warrant careful ethical
scrutiny. But to do so is a task that is ethical, not scientific.
In conclusion, in my review of the scientific context of therapy, I have
challenged a strict fact—value, science—ethics distinction in two ways: I
first argued that science produces facts that are relevant to values
(defined ethically); I then argued that ethical convictions, and the
discipline of ethics, can contribute to, indeed are intrinsic to, science. And
that extra-scientific values are often present in science, and need careful
ethical scrutiny.
To the extent scientific research is based not simply on empirical data,
but on data and the ethical beliefs of scientists, the practice of
psychotherapy (and our understanding of its ethical dimensions) will be
based on both science and ethics. Kurtines, Alvarez, and Azmitia (1990)
argue that we need to acknowledge that values are involved in science
and devote our energy to determining how they influence science. They
thus offer one reason we should turn to both science and ethics to
address ethical questions. I will now address others as I consider the third
challenge to scientism.
Science and ethics
Let me begin by reviewing my argument. The claim that the descriptive
enterprise of science can, by itself, provide knowledge about ethical
issues without drawing in any way on the methods and concepts of
ethics has faced two challenges: intrinsic to science are values (defined
ethically) and scientists often draw upon extra-scientific values in their
research. Regarding the first challenge, I have argued that ethics is, in
some regards, essential to science, so science is in every instance
intertwined with ethics. Regarding the second challenge, ethics can be
120 ETHICS AND VALUES IN PSYCHOTHERAPY
helpful to scientists in teasing out implicit ethical assumptions even if
scientists are capable of achieving valuefreedom. (Indeed, they may need
to draw upon ethics to identify implicit ethical assumptions before
eliminating them.) But in the more likely instance that extra-scientific
ethical assumptions are inextricably bound to the scientific effort,
scientists always draw upon some ethical concepts and methods, and
would benefit from doing so more openly, carefully, and systematically,
taking advantage of the concepts, methods, and history of ethical
reflection found in ethics.
But there is a third reason science alone cannot adequately understand
psychotherapy’s ethical dimensions: science cannot answer certain
ethical questions that ethics can answer.
Let me set forth what I think science (as traditionally understood) can
and cannot say about ethical matters. Science can describe but not
prescribe, can tell us what is but not what ought to be. Science can provide
facts—facts, for instance, about the consequences of an action and the
most effective way to reach a goal. But science cannot tell us at the most
fundamental level what is good, right, or virtuous. And science cannot
adjudicate conflicts between ethical principles (Sadler and Hulgus 1992).
Science cannot address ethical questions, Meehl asserted, because “the
value neutrality of a descriptive science obviously gives it no competence
to pass an ‘empirical’ judgment on the statement of a normative
discipline such as ethics, law or political theory.” But he added, “I have
yet to find a social scientist who makes this remark and is internally
consistent on this issue” (Meehl 1970:3).
The reasons for that inconsistency, discussed above, are manifold. But I
would propose one additional reason: many therapists believe scientific
knowledge does sometimes determine what is good or right. They assert,
for example, that scientific evidence documenting the efficacy of therapy
establishes that therapy is good, or that the empirical evidence that child
abuse harms children makes it clear that parents should not abuse their
children. As I argued above, science does make valuable contributions to
ethical deliberation. But science alone does not permit us to draw such
ethical conclusions, whether we employ a teleological (consequentialist)
normative ethical theory or a deontological normative ethical theory (see
the discussion in Chapter 4).
Waterman explains why we cannot draw ethical conclusions from
science alone when using a teleological normative ethical theory:
When philosophical teleologists claim that a behavior has moral
value because of its consequences, they are making two assertions:
(a) The behavior has certain specificable [sic] consequences, and (b)
those consequences are to be valued…. The latter assertion is not
empirical, however…. The adequacy of any statement that some
types of consequences constitute a better criteria of moral value than
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 121
do other types of outcomes can be judged only in philosophical
terms.
(Waterman 1988:292)
And so Waterman cautions that we cannot use “empirical evidence as the
ultimate criteria for deciding claims about what constitutes morality.”
Waterman’s qualification that empirical evidence cannot be the
“ultimate” criterion for deciding ethical claims is very important, as is the
qualification in my claim that science cannot tell us at the most
fundamental level what is good, right, or virtuous. Suppose we seek an
effective method for reducing depression. Reviewing the research
literature, we may be tempted to conclude that scientific evidence
documenting the efficacy of therapy establishes that therapy is good.
Scientific research thus appears to tell us that cognitive therapy is
“good.” But it can, in fact, only tell us cognitive therapy is instrumentally
good, not ultimately good, that cognitive therapy is good as a means to
reach the more fundamental good of reduced depression. We can only
draw the conclusion that cognitive therapy is good by combining
scientific findings and this more fundamental ethical judgment: it is good
to reduce depression. Of course, on some accounts, reducing depression
is good because reducing depression aids the survival of the species. But
in that case, human survival is the ultimate criterion (most fundamental
good) used in the ethical argument. As such, it must be justified, because
from the fact of human survival we cannot conclude that the end of
human survival is good or right. And so Strupp correctly concludes that
“the value of psychotherapy” cannot “be conclusively derived from
research” (Strupp 1986:129).
Teleological theories are especially important in evaluating the ethical
character of therapy, because therapy is often justified in terms of the end,
or goal, of improved psychological functioning or decreased
psychological problems. It is in these covert assumptions about the
goodness of therapy goals that much of the ethical character of therapy
lies (see the discussion in Chapter 9). But, reinforcing my point, Perrez
argued that “the positive foundation of the goals {of therapy} cannot be
adequately achieved scientifically” (Perrez 1989a:170).
And so, not science alone but science in combination with ethics
permits us to conclude that psychotherapy is good. We can validly draw
that conclusion from scientific findings that therapy reduces
psychological problems and the ethical claims that (1) we decide the
goodness of an activity by evaluating whether it brings about some
fundamentally good end and (2) reducing psychological problems (the
goal of therapy) is fundamentally good.
If we cannot derive ethical conclusions from science when we employ
teleological ethical theories, neither can we derive ethical conclusions
from scientific findings when we employ deontological theories. The
obligation to be honest, for instance, is not, and cannot be, a strictly
scientific finding.
122 ETHICS AND VALUES IN PSYCHOTHERAPY
And so, when striving to understand the ethical dimensions of
therapy, we should rely on both science and ethics. And when practicing
psychotherapy, which always includes those ethical dimensions, we
should draw upon both science and ethics.
Several advantages accrue to those who draw upon both science and
ethics. Doing so permits us to critically evaluate values intrinsic to science
as part of an axiology of inquiry. It permits us to detect extra-scientific
values in scientific research (our own and those of others), to try to
eliminate or minimize those values, or (perhaps) to choose those values
more wisely. Finally, therapists who base their practice, not only on
science, but also on science and ethics, can better address the ethical
dimensions of psychotherapy.
Drawing upon both science and ethics is not new. Prominent
psychologists, such as Wundt and James, have long been committed both
to experimentation and to philosophical reflection. Indeed, William
James remained concerned “simultaneously with normative ethics and a
scientific psychology” (Rambo 1980:50), as have Martin (1995), Perrez
(1989a, 1989b), and M.B.Smith (1961). Sadler and Hulgus have recently
articulated a particularly helpful model of clinical problem-solving, a
complement to the biopsychosocial model, that sets forth “three core
aspects of the clinical encounter: problems of knowledge, ethics, and
pragmatics” (Sadler and Hulgus 1992:1315). In their model, the clinician
ideally draws upon the sciences in making clinical decisions, but also
draws upon other disciplines, including ethics.
Unfortunately, some will no doubt interpret their model, and my
argument, as attacks on science. But Sadler and Hulgus’s model is not an
attack on science; nor is my argument. Nothing whatsoever prevents
scientists from conducting the highest quality scientific research yet also
drawing upon the discipline of ethics to address ethical questions.
Nothing whatsoever prevents psychotherapists from drawing upon
relevant scientific findings to guide their practice yet also drawing upon
the discipline of ethics to address ethical questions.
I suspect that some will misinterpret my argument because the ethical
claims of scientism are often confused with science itself. I reject scientism,
but I do not reject science. Again, one can conduct science and champion
relevant scientific findings without also claiming that science alone
provides us with valid claims to knowledge.
I do, however, hold a position similar to, but subtly and significantly
different from, one often held by advocates of scientism. I am convinced
that practice should be based on relevant scientific findings, when
available. Where science has a clear word to offer the psychotherapist, the
therapist ought to listen. And so, because I hold that ethical position, I
agree with Meehl’s ethical assertion that those who deny the need for
quantitative research are “unethical” (Meehl 1997:91).
I differ, however, from the advocates of scientism because I believe
that, when faced with a question for which relevant scientific knowledge
is not available, therapists need not rely upon scientific findings. Indeed,
since we cannot in principle obtain answers to some ethical questions
THE INTELLECTUAL CONTEXTS OF PSYCHOTHERAPY 123
from science, and since ethical issues are always a part of psychotherapy,
it would be absurd to expect therapists to base their practice solely upon
science.
“Psychotherapy should be based on science” was the claim with which
I began this section. And I heartily concur (on ethical grounds) that
psychotherapy should be based on relevant scientific findings. But
psychotherapy should also be based on ethics. And until
psychotherapists do so more explicitly and with greater sophistication,
psychotherapy will never reach its fullest potential.
Psychotherapists wanting a high degree of intellectual certainty will be
disappointed by my proposal. They recognize correctly that, absent
dogmatism, ethical reflection simply cannot promise such certainty. But
in contrast to those who use the scientific method to address all questions,
to obtain certainty, William James, according to Perry, argued:
in effect, that if a fact or a problem does not fit a technique, so much
the worse for the technique. If a problem cannot be solved by
rigorous mathematical or experimental procedure, then it must be
solved as well as possible. That problem is not solved by
substituting another problem that can be dealt with rigorously.
Indeed, it is quite possible that in the theoretical, as in the practical
field, the important problems are those which cannot be solved
rigorously—problems such as…value.
(Perry 1943:124)
I encourage the adoption of James’s approach. When we address the
ethical character of psychotherapy, we do well to address it “as well as
possible.” And that means, I am convinced, drawing heavily, wisely, and
well upon both science and ethics.
Conclusion
The scientific context of psychotherapy has both shaped and obscured
psychotherapy’s ethical dimensions in a variety of ways. Unfortunately,
dominant
understandings
of
science
have
overdetermined
psychotherapists’ avoidance of ethical discourse. The desire to be
objective and value-free, the failure to recognize values intrinsic to
science and the role of extra-scientific values in science, accepting the
false dichotomy of science or ethics, the ethical doctrine of scientism (that
human beings ought to be guided in all matters, including ethical, by
science alone), and the failure to recognize that scientism is an ethical
position and ought not be equated with science itself have all occluded
our awareness of the ethical dimensions of psychotherapy and prevented
us from thinking about them well.
124 ETHICS AND VALUES IN PSYCHOTHERAPY
On the other hand, values intrinsic to science (e.g. openness,
collegiality, and honesty) may be applicable to therapy. More
importantly, science provides helpful facts about consequences (e.g. the
consequences of dysfunctional beliefs or of particular forms of therapy)
that are often quite relevant to therapy and its ethical dimensions.
Consequently, science unequivocally makes important contributions to
the ethical character of therapy. And should do so.
But an optimal understanding of the ethical endeavor of
psychotherapy, and the psychotherapist as ethicist, requires that therapy
be based not only on science, but on science and ethics.
7
The social contexts of psychotherapy
Clinical practice and business
Almost all psychotherapy takes place, neither in the ivory tower of the
ethicist nor in the laboratory of the researcher, but in the concrete social
contexts of clinical practitioners whose livelihood is psychotherapy. We
need to understand those social contexts because, as Sarason notes, “the
substance of psychology cannot be independent of the social order”
(Sarason 1981:827). Because psychotherapy’s social contexts both shape
and obscure its ethical character, I will address them by focusing on
clinical practice and business.
The context of clinical practice
The arena of human suffering and disordered lives, the clinical context in
which therapy occurs, is both ancient and contemporary. Human need
preceded the development of modern psychotherapy, as did efforts to
produce human change (Gamwell and Tomes 1995; Grob 1994). And
there are decided continuities between psychotherapy, ancient healing
rituals, and other attempts to change people (Frank and Frank 1991).
Psychotherapists now perform tasks, including ethical tasks,
historically accomplished by others. Indeed, Freud asserted that “our
predecessors in psychoanalysis” were “the Catholic fathers” (Freud and
Pfister 1963:21). Therapists also inherited ideas, roles, and values from
other professionals, including other religious leaders, educators, nurses,
and physicians (E.Caplan 1998; Frank and Frank 1991; Hale 1971;
Holifield 1983; Levine and Levine 1970).
Psychotherapy’s medical heritage
I want to focus on only one of those professions, medicine, because it has
affected, affects, and has the potential to affect the ethical character of
therapy in a variety of especially significant ways. Bioethics, medicine’s
increasingly sophisticated ethical tradition, offers significant conceptual
resources to those addressing the ethical dimensions of therapy. But for
psychologists, psychotherapy’s medical context has too often obscured
126 ETHICS AND VALUES IN PSYCHOTHERAPY
the ethical dimensions of psychotherapy because psychologists resist
acknowledging the important ways in which medicine (and medical
ethics) has influenced therapy—and so they do not draw upon bioethics
as explicitly and fully as they could. Finally, critics charge that the
medical context has influenced the ethical character of therapy in at least
two deeply problematic ways: individualism and inappropriate uses of
the medical model that reduce those biopsychosocial problems that have
an ethical dimension to problems considered merely medical.
To address the ethical dimensions of psychotherapy’s medical
heritage, I will first address medical ethics, then turn to the medicalethical concept of “mental health.” Finally, I will consider many
psychologists’ curious resistance to draw overtly upon bioethics.
Bioethics: resource and source of problems
Medical codes of ethics—including and preceding the famous
Hippocratic Oath (Amundsen 1995)—have long codified the behavior
expected of physicians. Recent medical advances, increasing litigation,
and renewed philosophical reflection have given rise to the field of
bioethics (Beauchamp and Childress 1994; Engelhardt 1996; Gillon 1994;
Reich 1995a). As they seek to understand and address the ethical
dimensions of psychotherapy, psychotherapists of all professions can
fruitfully draw upon the ethical concepts, arguments, and discussions
generated by bioethicists, upon the recent emphasis on the virtues that
professionals should exemplify, and upon the development of clinical
ethical decision-making strategies.
I want to mention briefly two relevant concepts (there are more) from
medical ethics: the idea of the professional and a focus on the individual
client. All psychotherapists inherit both; both concepts are, in part,
ethical; both have deeply shaped psychotherapy.
As legatees of the social ethical idea of the professional,
psychotherapists are obligated, as professionals, to strive to benefit
clients and fulfill other duties (Haas and Malouf 1995). For example,
society can count on professionals, when “professional” is understood
substantively, to make the public welfare a primary concern (Watson
1954). This means, argues Orlinsky, that there is a distinctive quality to the
relationship between therapist and client, a decidedly ethical quality:
The innermost core of the therapeutic contract is a conception of the
ideal helping relationship, which often has an “ultimate” or
“sacred” quality. This inner ethical core also influences the
therapeutic bond by setting a model for it.
(Orlinsky 1989:435)
THE SOCIAL CONTEXTS OF PSYCHOTHERAPY 127
The ethical character of a “profession,” I am convinced, is central to
what it means to be a psychotherapist. But the meaning of “professional”
is eroding on two fronts: some people, corporations, and government
entities reduce the professional psychotherapist to mere “provider,”
jettison the ethical core of what it means to be a professional, and regard
therapists as nothing more than providers of certain services, like any other
providers of any other goods or services. And some psychotherapists
think the therapy relationship is entirely private, denying they are
accountable to anyone but their clients and tending to assert their rights
but not their obligations. Because this degradation of the meaning of
professional is so important, I will return to it in Chapter 11.
A positive thrust of medical ethics, concern for the well-being of the
individual patient, has a troublesome side as well, one that becomes
especially problematic in psychotherapy. The Hippocratic Oath, notes
Veatch, holds that “the physician’s obligation is to benefit the patient
according to the physician’s judgment” (Veatch 1989b: 46). Unfortunately,
in its modern form this principle “leads the physician to focus on the
patient as an isolated individual” and the profession of medicine to
become “ultra-individualistic” (ibid.: 48). That may be valid when a
malady is, in fact, wholly within an individual’s body (as is true with
some medical problems). But it becomes a problem when practitioners of
medicine (Veatch 1978) or psychotherapy (Doherty 1995) ignore the wellbeing of a community or of society as a whole, fail to balance concern for
self and others, or exhibit no concern for the natural environment.
And so Sarason argued that one of the roots of clinical psychology’s
deeply flawed “a-social” nature was that “it became part of a medically
dominated mental health movement that was…blind to the nature of the
social order” (Sarason 1981:833). As a result of that alignment with
medicine, and for other reasons, the psychotherapist became, in
Cushman’s words, “the doctor of the interior” (Cushman 1992:22). To be
sure, some approaches to medicine (e.g. public health) avoid
individualism. And psychotherapists need not draw upon the
individualistic strain in the medical heritage. But that strain exists and
has affected psychotherapy, often in ways invisible to those who
participate in it. And so it requires conscious attention.
A mixed medical/psychological/ethical concept: “mental
health”
The clinical context has changed. Problems once addressed in ethical
terms are now considered matters of “mental health,” to be addressed by
“mental health” professionals.
But it is a mistake to distinguish too sharply between ethics and mental
health, or to address all ethical problems under the rubric of mental
health. The relationship between health and ethics is complex. And
distinctions between the two, and concepts combining health and ethics,
128 ETHICS AND VALUES IN PSYCHOTHERAPY
have a long heritage. The powerful images of health and illness were long
ago extended metaphorically beyond the realm of physical illness.
Socrates thought of himself as a “physician” or “healer” of souls (McNeil
1951; Meilaender 1984), as did Plato and Aristotle (Taylor 1989), plus some
early Christian thinkers. And the twelfth-century Muslim mystic and
reformer, Al-Ghazzali, discussed diseases “of the heart” for which the
sole remedy is medicine derived from religious law (McNeil 1951:63).
Cross-fertilization of concepts occurred in other ways as well: ethical
convictions influenced medical convictions. Masturbation was held by
generally accepted medical opinion to be a “dangerous disease entity,” a
disease associated with serious physical and emotional problems
(Engelhardt 1974:234). And physician Samuel Cartwright, in a “Report on
the Diseases and Physical Peculiarities of the Negro Race” (1851),
delineated differences between African-Americans and Caucasians.
These differences were physical (“in the membranes, the muscles, and
tendons and in all the fluids and secretions”—Cartwright 1981:305),
behavioral (among the diseases discussed: “Drapetomania, or the disease
causing slaves to run away,” and “DYSAESTHESIA AETHIOPIS…A
DISEASE PECULIAR TO NEGROES—CALLED BY OVERSEERS,
‘RASCALITY’”—ibid.: 320), and ontological (“the great primary truth,
that the negro is a slave by nature, and can never be happy, industrious,
moral or religious, in any other condition”—ibid.: 311).
Although future generations may be as profoundly revolted by our
ideas about disease as most of us are by Dr Cartwright’s, there is now
widespread consensus that most disorders we now label physical illnesses
are appropriately labeled diseases. This does not mean, however, that we
no longer make ethical judgments when diagnosing illnesses. When we
label a problem a disease, we usually make ethical and medical
judgments. For instance, we make the nonmoral ethical judgment that it
is good to be free from cancer, and bad to have it. The widespread societal
consensus about such judgments may often, however, make their ethical
character invisible to us.
We also make nonmoral judgments about mental disorders. The Fourth
Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSMIV; American Psychiatric Association 1994), for instance, repeatedly uses
the value-laden criteria of “marked distress” and “impairment” in social,
occupational, or other important areas of functioning to differentiate
between disorders and problems that are not disorders. The DSM-IV
drafters clearly think it is not good for people to experience psychosocial
impairment and subjective distress. And even critics of the DSM-IV agree
that schizophrenia bears at least a close resemblance to physical illness.
And that it is a bad problem to have. Although we would not make
moral judgments about schizophrenia (e.g. “people should not become
schizophrenic”), we do make nonmoral ethical judgments (e.g. “it is not
good that my sister developed schizophrenia”). Moral ethical questions
tend to arise, not in the decision about whether a disorder exists, but in
what to do about it (e.g. “society ought to provide treatment for
schizophrenics, whatever the cost”; “we should help homeless
THE SOCIAL CONTEXTS OF PSYCHOTHERAPY 129
schizophrenics by taking them all off the streets and putting them in
hospitals”; or “the rights of all people, especially those labeled ‘mentally
ill,’ should be preserved”).
More controversial are other extensions of the medical model, or the
concept of “health,” to psychological problems. Kovel documents the
ways in which the mental hygiene movement produced a change in how
human problems were viewed: people were no longer considered “bad,”
but “sick” (Kovel 1980:82). And Freud powerfully expanded the concepts
of illness and medical treatments to include psychological problems and
treatments. He drew out analogies between physical disorders and
psychological problems and developed corresponding treatments.
Szasz (e.g. 1974) and others vigorously criticize the claim that
psychological problems are mental illnesses. Their concern is that—
whatever the commonalities—there are significant disanalogies between
physical illnesses and psychological problems. Commingling medical
terminology with psychological problems results, they claim, in
decreased responsibility, egregious violations of autonomy, and other
problems.
Often overlooked in debates about the medical model is the fact that
the concept of mental health—whether viewed in strictly medical terms,
in strictly psychological terms, or in terms of a biopsychosocial model—
contains an inextricably ethical component. For example, Margolis noted
that Freud produced a “mixed model that shows clear affinities with the
models that obtain in physical medicine and at the same time with the
models of happiness and well-being that obtain in the ethical realm”
(Margolis 1966: 81–2). And so Freud’s genital ideal served as a goal, an
ethical ideal, toward which a person undergoing psychoanalysis would
move. Improved self-esteem, self-actualization, and personal growth
later became common (value-laden) therapy goals.
“Mental health” and “mental illness,” in the case of Freud and others,
are thus value-laden terms (Caplan et al. 1981; Engelhardt and Spicker
1978). The extent to which they are value-laden hinges, in part, on how
health and illness are defined. We can view mental health either as the
absence of disease or as a positive state of well-being. Although, as we
have seen, values inform ideas about the former, there is greater
consensus about illness (and thus health understood as freedom from
illness) than there is consensus about health as a positive state of wellbeing. Part of the reason for this is that concepts of health understood as
positive well-being are generally more value-laden than concepts
stressing freedom from illness. And the concept of mental health is the
most value-laden of all.
But I think the failure of Jahoda (1958) and others to identify a
consensus among mental health professionals about the meaning of
positive mental health stems both from fundamental differences among
mental health professionals about the ethical ideals which underlie
various concepts of mental health or ideal human functioning, and from
their failure to discuss those ethical ideals.
130 ETHICS AND VALUES IN PSYCHOTHERAPY
When psychological problems are viewed in either strictly medical or
strictly psychological terms, however, the underlying ethical differences
are unlikely to be resolved: participants do not observe, no less discuss,
the ethical and other dimensions of psychological problems. As Schofield
(1964/1986) observes, psychiatrists have frequently failed “to appreciate
that the human suffers some pains not because he is sick but because he
is human” (Schofield 1986:146).
One reason for the poverty of ethical articulation that afflicts therapists
is that they are, in Jahoda’s words, “all trained to exclude values from our
thinking; and the way we try to exclude them is not to talk about them”
(cited in Schofield 1986:15).
From Jahoda’s diagnosis, one part of the treatment becomes evident:
we need to think and talk more about the ethical component of
psychological problems and therapy goals, however the broader debate
about medical and psychological aspects of human problems and change
processes is resolved. I will return to that task when discussing therapy
goals in Chapter 9.
Psychology’s curious estrangement from bioethics
Behind the puzzling resistance of US psychologists to draw overtly on
medical ethics lies the profession’s significant historical debt to medicine,
a debt of which many clinical psychologists are unaware or which may
would prefer to downplay. Although modern psychotherapy also drew
upon university counseling centers and community/child guidance
clinics (VandenBos et al. 1992), Strupp notes that “members of my
generation who first became acquainted with psychotherapy around 1950
have no difficulty perceiving its deep roots in medicine” (Strupp 1986:
120). Indeed, E.L.Kelly noted that “the term clinical {in ‘clinical
psychology’} is borrowed from its medical usage” (Kelly 1947:75).
But the medical influence on clinical psychology was by no means
limited to the adjective “clinical.” Before the Second World War, US
psychologists who conducted therapy in medical settings did so under
medical supervision (D.L.Moore 1992). The war brought major changes
for psychologists because the needs of military personnel far outstripped
the number of available psychiatrists. So psychologists began conducting
psychotherapy, but almost always under medical supervision (Abt 1992;
J.G.Miller 1946). After the war, the Veterans Administration sparked a
massive increase in the training of psychologists, who learned to become
psychotherapists under medical supervision (J.G.Miller 1946; D.L.Moore
1992). Cummings recalled that he and other psychologists who began
private practices in those post-war years “bootlegged their
psychotherapy training and supervision off campus from congenial
psychiatrists” (Cummings 1992:845).
And when psychologists in the American Psychological Association
began developing its own ethics code in the post-war period, Meehl and
THE SOCIAL CONTEXTS OF PSYCHOTHERAPY 131
McClosky (1947) pointed to the ethics codes of other professions,
including medicine. Until the APA developed its own code,
“psychologists had been largely bound by existing codes of other
professions, most notably medicine” (Wolman 1965, cited in Steere 1984:
20).
Psychologists did not want to remain in a perpetually inferior status to
psychiatrists. For that and other reasons, they sought professional
autonomy. But some psychiatrists had long been wary of psychologists
functioning autonomously as psychotherapists. Indeed, a “suspicious”
New York Psychiatric Society appointed a committee 1916 by “to inquire
into the activities of psychologists” (T.V.Moore 1944:472). The committee
concluded that “the sick, whether in body or mind, should be cared for
only by those with medical training,” unless under “direct supervision”
by a physician (ibid.). Deep disputes between psychologists and
psychiatrists continued in the 1920s (Burnham 1974; Goode 1960;
Seashore 1942). In 1937, Woodworth documented professional
“jealousies” with psychiatrists. Menninger (1943) referred to
psychologists who practiced therapy as “zealots.” Opposition continued
into the 1950s (Cummings 1992) and later. Indeed, psychoanalytic
institutes banned psychologists despite Freud’s support of “lay” analysts
(Abt 1992; Maher 1991), relenting only under court pressure to do so
(Practitioner Focus 1989). Clinical psychologists and psychiatrists fought
similar battles in the United Kingdom (Pilgrim and Treacher 1992).
Psychologists faced a daunting task: to obtain psychiatry’s prestige,
respect, financial rewards (Sarason 1981), status as independent
professionals (which was seen to require an independent code of ethics),
and societal sanction to do psychotherapy, while at the same time
distinguishing themselves from psychiatrists.
And so when they developed a code of ethics (Hobbs 1948), justified it,
and revised it, psychologists focused almost exclusively on its empirical
basis (McGovern et al. 1991; Nagy 1994; Sexton 1965). By doing so,
psychologists refused to depend on medicine (from which they were
trying to free themselves), distinguished themselves from psychiatrists,
built upon a distinctive strength of psychology (expertise in research),
developed a code targeted to problems for which the Hippocratic
tradition was not well suited (Raimy 1950), and forged their own identity
as an independent profession. Although they acknowledged drawing
ideas from social workers and psychiatrists, psychologists stressed the
untested nature of those ideas. Psychological research would test them,
making them scientific (Sexton 1965).
Like its earlier separation from its philosophical parent,
psychology’s separation from its medical parent may have helped it
become an independent profession. But the manner in which it did so has
made it difficult for psychologists to see the rich ethical heritage of
medicine and to take full advantage of bioethics as they addressed the
ethical character of psychotherapy.
Although bioethics should not be the sole source of the ethical
standards of the psychotherapist, I think it a very positive development
132 ETHICS AND VALUES IN PSYCHOTHERAPY
that some psychologists are now drawing more richly on bioethics (e.g.
the journal Ethics and Behavior, and K.S.Kitchener’s 1984 adaptation of
Beauchamp and Childress’s approach to medical ethics). Indeed, medical
ethics has likely shaped the ethical perspectives of psychologists more
than most would acknowledge. And bioethics offers resources far more
substantial than most are aware. And so therapists would benefit from
being aware of that influence and drawing selectively upon the expertise of
bioethicists in addressing the thorny issues of the ethical dimensions of
psychotherapy.
In conclusion, psychology has experienced an unfortunate double
estrangement from its moral sources, first from philosophy and then from
bioethics. (And a triple estrangement if we count its estrangement from
the spiritual and religious ethical sources of many of its practitioners and
clients.) If Taylor (1989, 1992) is correct (and I think he is) that ethical
sources move and motivate all people, and that we benefit from being
consciously aware of them and explicitly drawing upon them, then
psychotherapists would do well to identify, articulate, and build upon
their moral sources, including those found within psychotherapy’s
medical heritage.
Clinical reality
One final aspect of the clinical context deserves mention. Fine
philosophical distinctions and carefully delineated, bioethically informed
concepts of mental health fit the classroom well, but not the pragmatic
realities of actual therapy sessions. Therapists rarely have the luxury of
extensive insession reflection, and surely not of seeing a particular
moment of therapy in terms of the history of Western (or, better, global)
ethical reflection. The client speaks; the therapist must respond. Time is
not available to answer adequately all the ethical questions that arise in
therapy—if, that is, answering adequately means thoroughly researched,
academically reputable answers. Uncertainty is the lot of the therapist. As
Wallace notes, “while both clinicians and researchers trade in uncertainty
and ambiguity, the former must decide and act, often in the face of
insufficient information and inadequate theories” (Wallace 1991:90).
How, then, does a therapist respond? With the words of one’s best
supervisor gently echoing in one’s brain, with theoretical concepts, with
research findings, with reason, with one’s gut, within the context of one’s
own psychological framework. But also, one would hope, by reading and
reflecting—outside of therapy sessions—about ethics and therapy, so the
“spontaneous” responses in therapy sessions are shaped by careful ethical
reflection.
Addressing the pragmatic and ethical issues that face the clinician
(Sadler and Hulgus 1992) without fully satisfactory answers is probably
intrinsic to the endeavor. However, never engaging in thoughtful
THE SOCIAL CONTEXTS OF PSYCHOTHERAPY 133
reflection—about the goals of therapy, about the psychotherapist’s role as
ethicist, and about the ethical character of psychotherapy—is not.
The context of business
Paralyzed by anxiety about speaking in public but holding a job that
requires her to speak in public, Sandra seeks therapy. She knows she can
do so because her job has “good benefits.” Drawing on the understanding
of therapy she gained from traditional psychotherapy textbooks, Tania,
her therapist, establishes ground rules and goals for Sandra’s therapy:
Tania will provide a warm, empathic, and congruent relationship to
facilitate Sandra becoming fully functioning; Sandra will set and reach
her own goals as part of her “journey of personal growth.” Tania does
not think about the economic side of Sandra’s therapy because she is not
interested in business, the financial side of professional practice was not
covered in graduate school, and when she began her internship she was
told, “The Business Office will take care of that. Just concentrate on
becoming a good therapist.” Her supervisor, who came to professional
maturity when insurance companies routinely reimbursed therapists,
assumes Sandra’s therapy will be fully covered. And so Dr Schwartz
focuses on Tania’s need to rid her client of her maladaptive philosophy of
life (that is, of beliefs not in accord with the doctrines of Rational-Emotive
Therapy).
The managed care company Sandra chose to provide her medical
benefits will reimburse those therapists (and only those therapists) who
agree to reach the quality and cost-effectiveness goals established by
Sandra’s employer. To operationalize “quality and cost-effectiveness,”
Health Options has established a panel of scientists, which determined that
therapists can effectively treat in eight sessions those, like Sandra, with
Specific Phobias. In the absence of any clinical reason to vary from that
guideline, Health Options denies payment after Sandra’s eighth session
with Tania. Sandra, no longer fearful of speaking in public and unable to
pay $85 a session on her own, terminates.
Psychotherapy is, among other things, a business relationship.
Involving economic transactions between therapists, clients, and others
(Orlinsky 1989), therapy is a form of employment for therapists and an
expense for clients, businesses, and governments. As Rosenberg notes, a
profession is “a marketplace phenomenon—or, relatedly…an object of
government
policy” (Rosenberg
1979:443).
Understanding
the
psychotherapy profession therefore requires addressing its economic
context. That context can shape the ethical character of therapy in a
variety of ways, but it can also obscure it. For example, thinking of
Sandra’s therapy solely as one of her employer’s business expenses
obscures many of its ethical dimensions. But if the therapy goals put forth
by Tania and Dr Schwartz are good goals, or Sandra has the right to be
reimbursed for an unlimited number of therapy sessions, financial
134 ETHICS AND VALUES IN PSYCHOTHERAPY
considerations affected the ethical dimensions of Sandra’s therapy: her
rights have been violated and she does not reach the good ends
articulated for her by her therapist and therapist’s supervisor.
In the rapidly changing health care climate in the US (Austad 1996;
Moffic 1997; Trabin and Freeman 1995), the UK (Knapp 1995; E.Smith
1997; A.Williams 1994), and other countries (Desjarlais et al. 1995; H.M.
Sass and R.U.Massey 1988), complex economic forces are affecting
therapy, at times helping clients reach therapeutic goals, at times
preventing them from doing so, and consistently shaping the ways in
which people receive therapy. Consequently, “psychotherapists can no
longer practice as if psychotherapy were independent of its economic
environment” (Austad and Berman 1991a:3).
“The rape of psychotherapy” is how Ron Fox (1995:147), former
president of the American Psychological Association, described managed
care’s effect on therapy in the US. Karon called these new forms of health
care “a growing crisis and national nightmare” (Karon 1995:5). And
Blanck and DeLeon (1996) report that some consider managed care
immoral—because it is depriving clients of their rights and making them
powerless.
Powerful ethical convictions underlie those attacks on managed care
and make clear the close ties between economic and ethical
considerations. Fox contended that “the care of the sick, the damaged,
and the infirm cannot be done in a vacuum absent of values and moral
responsibility.” And, using explicitly moral language, he asserted that
“the wrongs that are being done in the name of saving money are simply
unconscionable” (R.E.Fox 1995: 147).
I will focus in this section on but a few key aspects of the complex
business context of therapy, those relevant to understanding ethical
dimensions of therapy. The business context of therapy is related to
therapy’s ethical dimensions in several ways. (1) Economic considerations
affect therapy—money can either facilitate therapy and help clients reach
good ends, or prevent that from happening. But (2) limited financial
resources have meant that third-party payers (governments, employers,
insurance companies, and managed care entities) are less and less willing
to pay for therapy, or are willing to pay for it only in circumscribed
circumstances. And so, critics charge, third-party payers violate clients’
right to receive health care and prevent clients from receiving therapy of
sufficient length to maximize their well-being. Third parties can thus
keep clients from reaching good therapy goals. But the third parties deny
those charges, arguing that they have eliminated unnecessary and
wasteful therapy, like long-term therapy for Sandra to reach goals
established by her therapist and her therapist’s supervisor, but not by
Sandra, for whom eight sessions of managed care therapy alleviated her
presenting problem, anxiety about speaking in public. They also
challenge the claim that people have an unconditional, unqualified right
to be reimbursed for an unlimited number of therapy sessions. (3) When
addressing therapy, some business entities consider economic considerations
alone (or are believed to do so). If psychotherapy is viewed only as a
THE SOCIAL CONTEXTS OF PSYCHOTHERAPY 135
business, decisionmakers try to eliminate all ethical considerations:
decisions about therapy are based solely on its economic costs and
benefits. (Ethical decisions are not eliminated, of course, but made in
particular ways, and implicitly.) (4) By way of contrast to such economic
reductionism, many therapists and managed behavioral health care
companies (see Trabin and Freeman 1995) argue that therapists, society,
and clients need to balance economic with other considerations. That is,
psychotherapy’s stakeholders can consider a society’s limited financial
resources and also address quality of care and professional ethical
considerations.1
Economic considerations and the ethical dimensions of
psychotherapy
If money is available to pay for therapy, clients can enter therapy and
potentially reach the goals (good or bad) set for them; if money is not
available, they cannot.
In general, those whose economic well-being is affected by therapy
want a say about its goals and the way it is conducted. Those who pay for
therapy or receive income from it—clients, therapists, and third-party
payers—are all interested in its goals (including goals considered good,
right, or virtuous) and about its process (how therapy is conducted, its
ethical character, and the number, frequency, and cost of sessions).
Clients generally want high-quality therapy at a reasonably low cost
(preferably covered by a third-party payer). Therapists vary in their
economic goals: some want only to earn enough to survive financially,
and some enough to thrive. Third-party payers want to be cost-effective
(spend as little as necessary) as clients reach therapy goals.
Striving to maximize one’s own financial well-being (whether
motivated by greed or by a desire for a fair financial arrangement) can
affect therapy. Indeed, health economists have proposed “target income
theory,” based on what McGuire characterizes as “the derogatory view
that physicians prescribe treatments not according to clinical norms but
according to the economic norm that they should make a certain amount
of money” (McGuire 1992:10). Therapists reject that theory, denying that
it explains the behavior of most therapists. They point instead to the greed
of third-party payers, emphasizing compelling stories like that reported
by Fox: “The chief executive officer of a major managed care firm
received salary, bonus, and stock options last year of $9.8 million, plus
dividends on his stock shares of $11.4 million!” (R.E.Fox 1995:150).
In fact, economic incentives can influence the actions of clients,
therapists, and third-party payers. Profit motivates all parties when free
market systems of health care operate (Salmon 1990). Such systems, note
Austad and Berman, are “subject to greed and misuse” (Austad and
Berman 1991c: viii). As A.Williams (1994) observes, when health care
professionals work with clients until they are as healthy as possible, care
can be limitless. When therapists provide interminable therapy, have full
136 ETHICS AND VALUES IN PSYCHOTHERAPY
caseloads, and receive standard fees, they do very well indeed. On the
other hand, some managed care arrangements provide both therapists
and managed care entities with strong financial incentives to undertreat
clients (Trabin and Freeman 1995). Greed can thus influence the behavior
of all therapy stakeholders.
Although corporations have financial incentives to undertreat their
employees, they have countervailing financial incentives to treat them
well. Corporations face the expense of therapy, but can benefit financially
from employees who receive it. Both mental illness and psychotherapy
have economic consequences (McGuire 1992). Untreated mental illness
and substance abuse among a corporation’s employees can harm a
company economically. And providing psychotherapy can produce
positive economic consequences for corporations. Positive medical
consequences can also result from psychotherapy. And since
corporations pay for medical treatment, the cost of providing
psychotherapy is offset by lower expenses for those medical problems
(Finney et al. 1991; McGuire 1992; VandenBos and DeLeon 1988).
Furthermore, some businesses provide therapy for employees assuming
it will result in better attendance records and safer, more productive
employees (Trabin and Freeman 1995). Freed from emotional burdens,
they can function on the job more effectively.
Fewer medical problems and higher productivity are good ends
(understood ethically) of therapy that benefit employers economically.
Because economic and ethical considerations converge, enlightened selfinterest motivates employers to provide employees with basic coverage
for mental health services.
Excessive economic self-interest (greed) among psychotherapists has
traditionally been kept in check, therapists argue, by professional
standards and codes of ethics (along with other factors). Since they are
supposed to further client well-being, professionals are not supposed to
provide unnecessary therapy, even if extra therapy is profitable. But this
assumes therapists are ethically motivated to benefit clients. Without the
“moral leverage” of ethical ideals, Doherty argues, “therapists who
advocate maintaining generous mental health insurance benefits sound
suspiciously like military defense contractors arguing that reduced
military spending will threaten national security” (Doherty 1995:3).
But the poverty of ethical articulation affecting most therapists makes
it difficult for them to provide convincing ethical arguments for the claim
that professionals are primarily concerned with the best interests of
clients. And the present system has spawned enough abuses that even
strong opponents of managed care (e.g. R.E.Fox 1995) acknowledge the
need for health care reform. But the current crisis in mental health
reimbursement has another, more fundamental source: differing ethical
visions of psychotherapy goals and processes. The modest ethical vision
of corporations and managed care entities often conflicts with the more
extensive ethical visions of therapists and clients.
Ethical ideas about psychotherapy—about good therapy goals and the
kinds of therapy that should be reimbursed—thus affect ideas about the
THE SOCIAL CONTEXTS OF PSYCHOTHERAPY 137
level of financial reimbursement for therapy. And the level of
reimbursement sometimes determines which therapy goals can and
cannot be reached.
Some insist that clients ought to determine therapy goals. Or that goals
ought to be determined by therapist and client with no interference from
“outside” parties. And indeed, as traditionally conceived, therapy
involved therapist and client alone, unbesmirched by crass economic
considerations. If clients and therapists were the only stakeholders in
therapy, they could, in free countries, pursue therapy in whatever way
they pleased. However, with the exception of therapy involving wealthy
clients able to afford therapy and therapists able to charge clients low or
no fees, most therapy is paid for, in part or in full, by some third party.
And so other stakeholders are often concerned about therapy
relationships. And the economic and other factors introduced by such
third-party payers are now significantly shaping therapy’s ethical
character.
But this third-party involvement, and its consequences for the ethical
character of therapy, is not new. Business became involved in counseling
in the US at a relatively early stage in its development. Corporationsponsored therapy aimed at the goal of adjustment (Baritz 1960).
Assuming the happy worker was a productive worker, one unlikely to
join a union, Western Electric began to provide counseling to employees
in 1936, conceiving of it as “a method of helping people think in such a
way that they would be happier with their jobs” (Baritz 1960:104).
More widespread corporate involvement in psychotherapy did not
develop until the 1960s and 1970s when health insurance programs began
covering psychotherapy (VandenBos et al. 1992). The therapeutic contract
thus involved therapist, client, and third-party payer, a tripartite
arrangement much more complicated, difficult to understand, and
impersonal than that negotiated by therapist and client alone. But
VandenBos, Cummings, and DeLeon pointed out that “economic factors,
such as government support and insurance reimbursement, have played
a major role in making psychotherapy a viable social enterprise and
profession” (VandenBos et al. 1992:97). Reimbursement meant more
people could receive therapy. And they did. The number of mental health
professionals grew accordingly, with the number in the US increasing
from 23,000 in 1947 to 121,000 in 1977 (Kiesler and Morton 1988) and the
number of US psychologists jumping over 300 percent from 1974 to 1992
(Frank and VandenBos 1994).
Many factors led to widespread health insurance (Starr 1982), including
the high cost of treatment, laws mandating mental health coverage, and
ideas about a right to health care. Unions and others negotiated for health
insurance as an employee benefit, and then for mental health coverage,
because reimbursed treatment for physical and mental health problems
was seen to be good. Insurance companies placed some limits on
coverage, including lifetime maximum benefits, deductibles to be met
before reimbursement would begin, requiring clients to cover part of the
cost, and, most significantly, limiting coverage to diagnosable mental
138 ETHICS AND VALUES IN PSYCHOTHERAPY
disorders (Starr 1982; Trabin and Freeman 1995). The last was important
because third parties began dictating which therapy goals would result in
reimbursement: once a client no longer suffered from a diagnosable
mental disorder, reimbursement purportedly stopped.
But traditional indemnity insurance plans, at first the most common
type of insurance, required little interaction between third-party payer
and professional (Starr 1982) and, from the perspective of the therapist,
little interference. Insurance companies trusted therapists to diagnose
accurately. And many therapists saw few clients who would not “fit” into
some diagnostic category.
But in response to increasing health care costs, federal legislation, and
other factors (Trabin and Freeman 1995; VandenBos et al. 1992), new forms
of third-party payment for mental health problems developed rapidly in
the 1970s and 1980s. The “quiet” third party in psychotherapy began to
speak more loudly and “interfere” in therapy in unprecedented ways.
Third-party payers began to manage care previously managed by
therapists, and to pay for therapy in some circumstances but not others.
And self-insured employers questioned funding long-term therapy aimed
at clients’ personal growth (Trabin and Freeman 1995).
Therapists responded angrily to the new limits placed on them. They
raised a wide range of complaints, especially about denial of payment for
treatment, and denial of payment for treatment deemed too long (R.E.Fox
1995; I.J.Miller 1996; Seligman 1996). The “corporatization” of health care
(R.E.Fox 1995; Salmon 1990) was decried, because the new health care
corporations were allegedly concerned about profits, not patients
(Eisenberg 1986), and failed to exhibit compassion or a commitment to
equity, quality, or any social obligation to the poor. Seligman raised other
concerns about Managed Care Organizations (MCOs):
(a) MCOs endanger three basic patient rights: choice of provider,
facility, and modality; personal privacy; and decision-making ability.
(b) MCOs make clinicians directly economically dependent on insurers,
and thus frequently create a conflict between the well-being of the
patient and the operating profits of the MCO company or insurer.
(c) MCOs “deprofessionalize” care by hiring the “cheapest” person
willing to do the work….
(d) Treatment decisions based on the judgment of the consumer and
clinician should be primary. They should not be subordinated to the
judgment of insurers, case mangers [sic], or employers.
(Seligman 1996:5)
Seligman thus raises profound ethical questions about managed care.
Trabin and Freeman (1995) acknowledge that managers in some forms
of managed care, especially during periods of rapid growth, have
exhibited poor clinical judgment, inappropriately denied treatment, and
harmed clients. However, they stress the diversity of managed care
THE SOCIAL CONTEXTS OF PSYCHOTHERAPY 139
providers (see Austad 1996), noting that most problems occurred with
those that limited mental health expenditures to 3 percent of total health
expenditures. Entities spending 7 percent provided quality care and were
still cost-effective, spending less than the average of 10 percent devoted
nationally to mental health care. However, Trabin and Freeman voiced
concern about survey findings suggesting that those who purchase health
services are perceived to be more concerned about cost and less about
quality of care. Since most of psychotherapy’s ethical dimensions have to
do with matters of quality, the direction that evolving systems of health
care take in the future will have profound effects on the ethical
dimensions of psychotherapy.
Careful analyses of the financial incentives in various approaches to
therapy reimbursement and the trend of greater accountability will likely
be of particular importance in determining how economic factors shape
psychotherapy in the future. That is important because the ethical
character of therapy will be determined in part by financial incentives
and in part by the ways in which third-party payers, therapists, and
clients are accountable to one another.
The economic incentives found in traditional forms of insurance pull
therapists in the direction of overtreating clients (Trabin and Freeman
1995). One reason is the unique nature of traditional indemnity health
insurance (Starr 1982): within limits, the more therapists bill insurance
companies, the more therapists get paid. So, therapists have a financial
incentive to find “disorder,” to provide extensive treatment, and to
charge increasingly steep fees. Health care is thus disconnected from the
market forces that exist in other businesses. Although health insurance
for mental health problems is ostensibly limited to demonstrable mental
disorders, reimbursement is sometimes sought for therapy with people
whose problems do not meet strict diagnostic criteria. It is extended to
the “worried well,” to persons suffering from ordinary unhappiness
(Schofield 1986). Indeed, Regier, Narrow, Rae, Manderscheid, Locke, and
Goodwin (1993) estimated that, of the 23.1 million Americans seeking
treatment each year in the de facto mental and addictive disorders service
system, 10.4 million did not meet the diagnostic criteria for any current
mental disorder. Of that 10.4 million, 34.1 percent had past, but not
present, diagnoses. That leaves 6.8 million Americans with no (past or
present) diagnosable mental disorder receiving mental health/substance
abuse services.
By way of contrast, the economic incentives in some forms of managed
care pull companies and therapists in the direction of undertreating
clients (Austad and Berman 1991b). Research in the field of economics
and mental health has made it clear that the specific features of a payment
system substantially influence access to therapy, the quality of the care
provided, and its costs (McGuire 1992). This is especially true in the arena
of mental health, where demand for services varies with the availability of
reimbursement more than the demand for physical health services varies.
Consequently, US mental health costs grew at an even faster rate than
other health care costs (Broskowski 1991). Although much of this increase
140 ETHICS AND VALUES IN PSYCHOTHERAPY
has been attributed to the expenses of inpatient treatment (I.J.Miller 1996),
ambulatory mental health organization expenditures in the US grew from
$388 million in 1969 to $5.3 billion in 1988, with expenditures in per
capita constant dollars going from $1.94 to $4.96 (Redick et al. 1992). That
is, when controlled for inflation, the costs of ambulatory mental health
services increased 156 percent.
To control costs, some managed mental health care entities mandate
greater therapist accountability. Third-party payers expect the
psychotherapy professions to provide empirical evidence for the
effectiveness of psychotherapy and individual providers to document the
progress clients make and follow practice guidelines (R.E.Fox 1995). But
Fox, while acknowledging the need for therapists to be more
accountable, argued that managed care companies need to be more
accountable as well. For example, he noted they require therapists to
maintain liability insurance but some have attempted, unless legally
prohibited from doing so, to “avoid responsibility for the adverse effects
of their decisions on patients” (ibid.: 150). Similarly, I.J.Miller (1996)
argued that managed care entities should provide consumers with
accurate information about cost and quality so they can make wise,
informed decisions about their health care. And, in fact, Trabin and
Freeman report that some purchasers of health care services are
beginning to require managed care entities to be more accountable, for
example, by developing “outcomes management programs” and
providing “data from them periodically in order to demonstrate clinical
effectiveness and value” (Trabin and Freeman 1995:20). As Austad notes,
“all managed care is not the same” (Austad 1996:6). Greater
accountability will permit all therapy stakeholders to make more
informed evaluations of specific managed care entities. One way in which
managed care organizations are being made more accountable is by
providing potential clients (consumers) and other interested parties with
evaluations of each managed care organization that offers services to a
given population (Knutson et al. 1996). In Indiana, for instance, service
providers are rated annually on a “Provider Profile Report Card” which
“describes the relative performances of each of the service providers”
(Newman et al. 1997:1).
This call for accountability could produce an important dialogue about
the ethical dimensions of psychotherapy because all parties are expected
to be forthcoming about the value-laden issues of therapy goals, therapy
effectiveness, and the quality of services provided.
Unfortunately, however, this demand for accountability can disrupt
the clinical relationship and pose serious threats to confidentiality
(R.E.Fox 1995). If decisions about therapy goals and length of sessions are
made by those third parties alone, both client and therapist are
disempowered and their freedom is abridged. And very private
information may need to be sent to third parties. Client confidentiality
may be compromised.
Differing financial incentives and demands for accountability shape
(and will shape) the ethical character of therapy because clients,
THE SOCIAL CONTEXTS OF PSYCHOTHERAPY 141
therapists, and third-party payers have very different perspectives on
psychotherapy. Behind those differences and behind economic decisions
lie ethical differences among psychotherapy’s stakeholders. They hold
different visions about which therapy outcomes and which therapy
processes are good, right, or virtuous and so make different choices.
Corporations sometimes appear to make decisions about therapy solely
on cost considerations. If a corporation’s business advisor were told,
“Tell this corporation how to make more money,” the answer with regard
to psychotherapy might be “Therapy that is as short as possible,
inexpensive, efficient, and not wasteful, and that avoids hospitalizations
and lawsuits, decreases expenses, maximizes productivity and profits,
and reduces expenditures for medical treatments.” The de facto ethical
ideals in the corporation’s economic interests are evident in that list. By
way of contrast, if a therapist’s business advisor were told, “Tell me how
to make more money,” the reply might be “Therapy that is long,
expensive, fully or mostly reimbursed, and accessible to everyone in a
society. Therapy in which therapist and client alone set goals. And
therapy that involves little or no paperwork and produces satisfied
clients who refer new clients to you.” The de facto ethical ideals in the
therapist’s economic interests are evident in that list as well.
The business context of therapy affects its ethical character in another
way, by way of the societal structures through which therapy is provided.
Those structures reflect ethical ideals. As H.Sass points out, “the
structures that exist to provide health care in different national settings”
reflect “moral presuppositions and underlying ethical considerations”
(H.M.Sass 1988: xiii). Those structures, Sass argues, warrant careful
analysis. In analyzing the changes in US health care, Salmon (1990)
complained that ethical ideals present in more traditional forms of health
care, for example, free or low cost hospital care for the poor, have
disappeared in newer forms of health care. (Nothing, save financial wellbeing, prevents therapists in private practice from offering free or lowcost therapy, however.) And many therapists are convinced the primary
commitment of managed care entities is cost effectiveness, not quality of
care.
Limited financial resources
Many Americans believe they spend too much on health care for what
they receive (M.A.Hall 1997). That is, many believe that too large a
percentage of the US Gross National Product is devoted to health care.
That fact must be faced. It represents both a crisis of social ethics (raising
profound questions of distributive justice, since many Americans lack
health insurance), and an economic problem of the first magnitude for
those ultimately paying for psychotherapy, which includes taxpayers. As
Austad and Berman put it, “costs have increased so dramatically that
employers, insurers, and individual consumers are no longer willing to
142 ETHICS AND VALUES IN PSYCHOTHERAPY
pay unlimited amounts for health care without close scrutiny and
accountability” (Austad and Berman 1991a:3).
The US devotes 14 percent of its Gross National Product (GNP) to
health care (M.A.Hall 1997), 40 percent more than any other developed
country (R.G.Frank 1993). Davis (1989) notes that US expenditures are in
contrast to the 6 to 9 percent of GNP spent by most European countries
and Japan. And Davis adds that, although health spending as a
percentage of national productivity stabilized in those countries during
the 1980s, the percentage continued to grow in the US. Sensenig, Heffler,
and Donham (1997) reported that in the mid-1990s, US health care
expenses (as a percentage of GNP) finally began to stabilize, due to
managed care. As noted above, the percentage of health care
expenditures devoted to mental health had been growing even faster
than the overall growth of health care expenditures (Broskowski 1991).
Costs escalated as benefits expanded.
Limited resources for psychotherapy is a global problem (Desjarlais et
al. 1995; Knapp 1995). As Williams notes, all societies work within budget
constraints and restrict “good” health care: “No society can afford to offer
all its members all the health care that might possibly do them some
good. Each society has therefore to establish priorities” (A.Williams 1994:
829). The great difficulty of doing so, an ethical difficulty, is that
“expanding one good thing will always be at the expense of other good
things” (ibid.: 830). Any country could greatly expand the availability of
psychotherapy, maximizing the good that therapy produces. Doing so
might, however, mean losing some of its productivity and global
competitiveness. Therapists would do well in that scenario, but not
workers who lose jobs to foreign competition because high health care
costs forced their employers out of business.
Employing economic considerations alone
In the face of those economic pressures and the perceived need to reduce
health care costs, one set of “solutions” presents itself: take into account
only economic considerations, permit them to trump all others, or make
them primary. Although many therapists feel this valorizing of economic
considerations, this economic reductionism, characterizes all or most
managed care entities, I am disinclined to think it true of all. I do not raise
the issue of economic reductionism, however, to make an empirical claim
about managed care. I do so to clarify the ethical implications of viewing
psychotherapy in exclusively economic terms. Unless educated in the
virtues of taking a broader perspective on psychotherapy, the business
school graduates increasingly in charge of health care reimbursement
will view psychotherapy in primarily financial terms. Those, like me,
who think it important that psychotherapy stakeholders consider
economic and ethical issues in making decisions about therapy
THE SOCIAL CONTEXTS OF PSYCHOTHERAPY 143
reimbursement need to know the logic likely to be used by those thinking
exclusively in economic terms in order to respond to them effectively.
Two features of an exclusively business perspective are especially
relevant to the ethical character of therapy: the common (but fortunately
not universal) lack in business of an ethical analysis of the ends or goals of
psychotherapy, and reducing therapists to commodities, treating them
like any other business product.
In MacIntyre’s (1984) analysis of contemporary culture, the figure of
the manager is central. The manager works in an organization, for
example, a corporation or government bureaucracy, that exists to further
certain ends. The task of managers is to “direct and redirect their
organizations’ available resources, both human and non-human, as
effectively as possible toward those ends” (MacIntyre 1984:25). Those
ends are given to the manager; it is not his or her task to think about them
because, as MacIntyre notes, “questions of ends are questions of values,
and on values reason is silent” (ibid.: 266). It is, however, the task of the
manager to be effective in achieving assigned ends. And about
effectiveness, rational judgments can be made.
If the primary end of the corporation is profit, the manager assigned
the task of determining mental health benefits will seek to maximize
corporate profits when determining mental health benefits. The manager
may thus reduce or subordinate the goals of therapy—autonomy,
freedom from mental illness, mental health, self-actualization, insight,
healthier primary relationships, and so forth—to economic
considerations, to numbers on an accountant’s spreadsheet. The intrinsic
goodness of those ends, or any sort of qualified right of individuals to
receive treatment to achieve them, will be lost from view. Lost, that is,
unless therapists and others articulate clearly psychotherapy’s
pervasively ethical character.
A second problem produced by an exclusively business approach to
psychotherapy is viewing the therapist as a commodity, exchangeable
with any other therapist. “Commodifying” the therapeutic relationship,
making therapists commodities or providers of a commodity named
therapy, making therapy “just a business relationship,” permits a
therapeutic relationship to be terminated as any other business
relationship is terminated. And, in fact, some managed care entities have
informed clients/employees by mail that their long-standing therapeutic
relationships would, after a date in the near future, no longer be
reimbursed, adding that the client/employee could contact a substitute
therapist who would meet any mental health needs the managed care
entity chose to authorize. This ignores the empirical evidence about the
importance of the therapeutic alliance (Horvath and Greenberg 1994;
Orlinsky et al. 1994). Furthermore, treating clients and therapists as
means to an end, and not as ends in themselves, violates Kant’s basic
ethical principle that people should always be respected as worthy in and
of themselves, as ends, and never merely as means to some end.
144 ETHICS AND VALUES IN PSYCHOTHERAPY
Let me provide a second example of the clash of business and
therapeutic cultures, of the failure of an exclusively business perspective
to take seriously professional standards and ethics, the importance of
therapeutic relationships, and client well-being. This example is from my
own experience. I was socialized in a therapeutic culture that placed
primary emphasis on client well-being and took the client-therapist
relationship very seriously. For example, long-term and vulnerable
clients were prepared to cope with their therapist’s vacations well ahead
of the therapist’s departure. After completing my internship, I joined a
clinic that, through a complex process, became part of a corporation that
attempted to expand to provide behavioral health services across the
nation. The attempt to expand failed, leading to layoffs and the
Chapter-11 bankruptcy of the parent company of the clinic at which I
worked. But clinical services continued and optimism was expressed
about the long-term viability of the local clinic. But one morning, the day
after I returned from vacation, I received a phone call informing me that
the clinic had filed for a Chapter-7 bankruptcy and would close at 5 p.m.
that day. I was unable to reach the client I had scheduled at 6 that
evening, but was told she would be notified of the clinic’s closing and
told how to contact me so we could continue therapy. The client was not
notified, nor was I notified she was not contacted. And so she showed up
for her appointment to find the door locked, the clinic shuttered.
Although this client was unperturbed and a colleague loaned me his
office until I could make more permanent arrangements, it became
evident to me that an exclusively economic and legal approach to the
business of psychotherapy led to a decided callousness to client wellbeing and to the importance of “intangibles” like the therapeutic alliance.
That is, a strictly “business” approach to therapy can lead to serious
ethical problems.
To be sure, economic evaluations of mental health delivery can be
conducted, indeed, should be conducted, with greater sensitivity to the
persons involved and to therapeutic alliances. In this regard, Knapp
(1995) provides a helpful alternative, outlining four principles—
economy, efficiency, effectiveness, and equity—that economic
evaluations of therapy can employ so the evaluations are not narrowly
economic, but include ethical components as well.
But therapists’ failure to be explicit about therapy’s ethical dimensions,
of the goodness of therapy ends and the irreducibly important (and
ethically vital) therapeutic alliance, will lead to a problematic reduction
of psychotherapy to nothing but an economic problem. Unless, that is,
therapists and others make a clear and convincing case for the
importance of ethical considerations in therapy. As Doherty notes,
“therapists’ failure to attend to the broader moral and community
dimension has left psychotherapy vulnerable to being managed as just
one more commodity in the health care marketplace” (Doherty 1995:8).
THE SOCIAL CONTEXTS OF PSYCHOTHERAPY 145
Balancing economic with other considerations
The obvious solution to the problems of thinking about therapy in solely
economic terms is for psychotherapy stakeholders to use non-economic
considerations as well, especially those that are scientific and ethical.
Although McGuire (1992) notes that introducing professional norms into
economic evaluations of health care systems makes them more complex,
he thinks that doing so makes the evaluations more adequate. Yates
(1995) articulates the need for scientist-manager-practitioners with
expertise in both science and business. He also describes models for
research and practice that take into account both science and business.
Fox noted that “the laws of the marketplace are ill-suited” for the work of
caring for others, but acknowledged the legitimate needs of purchasers of
mental health services. Their business needs can be met, he argued,
“without destroying the integrity of the psychotherapeutic contract”
(R.E.Fox 1995:147, 149). Likewise, Knapp noted that economics “cannot
replace the judgments of decision-makers, but it ought to be able to
supplement and inform them” (Knapp 1995:23).
Knapp and others have articulated criteria that psychotherapy
stakeholders can use, in conjunction with cost-effectiveness, to improve
the systems through which psychotherapy is provided. Knapp suggested
economy, efficiency, effectiveness, and equity. Trabin and Freeman
(1995) argued for improving value and quality along with costeffectiveness. And, as noted above, Fox (1995) stressed the importance of
the integrity of the therapeutic contract. Finally, Abe-Kim and Takeuchi
(1996) suggested cultural competence, a component of the quality of
services provided, as a criterion by which managed care should be
evaluated.
To determine whether a particular system of managed care has met
those criteria, we need to draw upon economics, science, and ethics.
Ethical analysis comes into play, for example, when we define what
“quality” means in psychotherapy or consider the goodness of the goals
we use to determine whether therapy is “effective.” Ethical analyses are
also relevant when evaluating the quality of the relationship between
therapist and client, the ethical character of that relationship. Finally,
addressing equity, the fair distribution of therapeutic services, requires
social ethical reflection, reflection that considers not just the therapist and
client, but the needs of a society as a whole.
And so therapists, if taking into account scientific, business, and ethical
concerns, must expand the traditional identity of therapists as
professionals concerned exclusively with their clients. As Knapp (1995)
and Austad (1996) note, therapists have duties to patients and to the
public.
In summary, by pointing beyond the therapy dyad to the broader social
context, the business context of therapy shapes our understanding of its
ethical character. It does so in other ways as well, like providing the
146 ETHICS AND VALUES IN PSYCHOTHERAPY
resources to reach therapy goals which we believe to be good. But
business considerations also block clients from reaching their goals. And
employing economic considerations alone can block from our view the
ethical character of therapy. In the current economic climate, the ethical
character of the therapy relationship and of therapy goals is especially
likely to be lost in debates over cost-effectiveness. And so it is especially
important that therapists clearly articulate the ethical basis of therapeutic
relationships and therapy goals, the ethical character of therapy process
and outcome. It is to those topics I will turn in Chapters 8 and 9.
Conclusion
Any psychotherapy session represents the culmination of a long and
variegated series of interlocking sociohistorical developments. I have
argued that the ethical, scientific, clinical, and business contexts of
therapy have shaped, and continue to shape, the ethical dimensions of
psychotherapy. At times, those contexts have also obscured, and obscure,
those dimensions. Because those contexts influence therapists, clients,
and third-party payers in rich, subtle, and powerful ways, they shape the
ethical character of psychotherapy.
Part IV
Change in psychotherapy
Ethical facets
8
Ethical dimensions of the techniques,
strategies, and processes of therapy
Which means to therapeutic ends?
To evaluate the ethical character of what occurs during psychotherapy, we
need to think carefully about the goodness, rightness, and virtues of the
various techniques, strategies, and people in therapeutic relationships.
Consider this vignette:
“My life is messed up. And my sister and my boss both told me I
should get some help.”
After those opening words, Bob, a 33-year-old foundry worker,
describes his situation. His second wife has left him, perhaps
permanently. With the help of his extended family, he is taking care
of their three children, a 10-year-old girl from his first marriage, a 9year-old boy from his wife’s first marriage (Bob adopted him and
considers him his own), and a 3-year-old daughter from their
marriage together. Bob’s 28-year-old wife left him to live with a 23year-old she met over the Internet. That relationship, however,
appears to working out less well in person than in cyberspace.
After providing those skeletal facts, Bob continues, “And now I’m
really confused. Should I forgive her and try to work it out? Or
forget about her and get on with my life? I’ve done it before. I
mean, start over. But I had only one kid then, not three. But I could
do it.
“So what should I do? That’s my question. That’s why I’m here.
What do you think?”
Dr Peterson asks a variety of assessment questions. He learns that
Bob is suffering from mild-to-moderate levels of depression and
anxiety. Bob reports functioning well at work and having a good
relationship with all three children. But he states he doesn’t feel
very good about himself as a husband. In the course of the four-year
marriage, he has been verbally abusive to his wife, and she to him,
although no physical abuse has occurred. Wrathful arguments have
broken out in the four months since they separated, with the
children at times within earshot. And once a month or so, Bob
“copes” by getting drunk. He goes to a neighborhood bar, returning
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 149
home at closing time and leaving the children in the care of his
oldest daughter. When questioned about the wisdom of this, he
reacts defensively. “Look! My daughter is very responsible. Plus, the
next door neighbor is right there if a problem comes up.”
Although tending to externalize blame, Bob has occasional selfreflective moments in which he becomes painfully aware of how far
his present life is from his ideals for it (e.g. “I believe in marriage,
but I’m a two-time failure as a husband. I mean, how bad can you
get? My life wasn’t supposed to turn out this way.”) A conservative
(but not a fundamentalist) Christian, he just began participating
with other men in his church in the Promise Keepers men’s
movement. As a result, he says, he knows he needs to accept more
responsibility for his actions. He is warm and affectionate with his
children, performs the full range of household responsibilities in the
absence of his wife, and espouses a belief in traditional sex roles.
As the initial therapy hour draws to a close, Bob becomes agitated
and angrily demands, “We’ve been talking for an hour now, but
you still haven’t told me what to do about my problem. What should
I do? Forgive her?”
Dr Peterson reacts strongly and emotionally to what feels to him
like an attack. In accord with his analytic training, he notices and
processes his reaction: he knows his own affairs played a role in his
divorce. “But only in small part,” he tells himself. “My wife’s
unwillingness to forget about those little ‘adventures’ of mine was
the biggest part of the problem.” Dr Peterson also wonders whether
his class and religious differences with Bob are playing a role in his
reaction. But he also thinks about Bob’s strong desire to have an
authority figure tell him what to do, thinking in terms of
transferential issues, unconscious motivation, and the early
childhood origins of Bob’s problems. And he keeps in mind Freud’s
doctrine about therapist self-disclosure: “The doctor should be
opaque to his patient and, like a mirror, should show them nothing
but what is shown to him” (Freud 1958:118).
And so he simply says, “I don’t want to impose my values on you.
That wouldn’t be fair to you. But I think therapy is a good idea for
you. An objective professional can help you sort out your feelings
about all this and make a decision. And don’t you worry about
paying for this. I know how to handle these managed care
companies.” He chuckles, and says to Bob, “Let me ask you one
more question: Have you ever in your life felt, even a little bit, like
you’d rather be dead than alive?”
“Well, yes,” says Bob, somewhat startled. “But I’d never do
anything. Especially not with three kids.”
150 ETHICS AND VALUES IN PSYCHOTHERAPY
“Good,” replies Dr Peterson, saying to himself “Close enough,”
and checking off “suicidal” on the managed care evaluation form.
He then looks up at Bob and says, says, “I’ll get you all the
sessions you want. I can see you again next Wednesday at 4.”
To address well the ethical character of the processes of Bob’s therapy, of
any therapy relationship, or of therapy in general, we need to begin by
rejecting a pernicious falsehood: therapists either provide “objective,
value-free” therapy or “impose” their values on clients. Dr Peterson’s
options are far wider than either being neutral or coercing Bob into
adopting his views.
Much of this book has been a sustained argument against the
possibility of value-free therapy. It is also not possible, with rare
exceptions, for therapists to impose their values on clients. Influence, yes;
impose, no. In general, therapists simply do not have enough power over
clients to impose their views on them. Indeed, if therapists could impose
values, they could impose mental health, quickly eliminating the problems
clients bring to therapy. Therapy would be universally effective; we
would need few therapists.
Between the alternatives of “imposing” values and “value-freedom” is
a rich and fascinating middle ground. Murkier, to be sure, than either of
those alternatives, but holding the ultimate promise of being both more
realistic and more satisfactory. More fine-grained analyses of the ethical
dimensions of the therapy process require an exploration of that middle
ground, as well as other pertinent issues. Indeed, the processes of Bob’s
and other clients’ therapeutic relationships involve many ethical issues.
Therapy process and ethics
Perrez (1989b) suggests that we can evaluate the “ethical acceptability” of
therapy methods, plus the “ethical legitimacy of…therapeutic goals”
(Perrez 1989b: 140). We can thus evaluate the ethical dimensions of both
therapy process and therapy outcome, a traditional distinction I am using
to divide the material in Chapters 8 and 9.
By process, I mean whatever occurs during psychotherapy. As
Orlinsky, Grawe, and Parks (1994) point out, researchers have labeled a
variety of therapy techniques, states of relationship, methods, and so
forth as “process.” These processes can be evaluated (often with very
different results) from the perspective of clients, therapists, and outside
observers. They can also be evaluated in terms of the types of change
clients experience, of specific events in therapy (e.g. the “actions,
perceptions, intentions, thoughts, and feelings of the patient and
therapist, as well as the relationship between them”—Orlinsky et al. 1994:
274), of what causes outcome, and of sequential descriptions of what
occurs. And we can employ multiple levels of description. Finally, Frank
and Frank (1991) argue that because psychotherapy addresses, and alters,
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 151
the meanings which clients attribute to life events, those crucial meaningmaking and meaning-altering processes warrant the careful attention of
anyone striving to understand therapy. All of those dimensions of
therapy process can be evaluated ethically.
Psychotherapy process and outcome overlap (Lambert and Hill 1994).
For example, some would argue that Bob accepting greater responsibility
for his actions is a vitally important means (a process) by which
therapeutic goals can be reached. But others would consider his
acceptance of greater responsibility a therapeutic goal (an outcome). And
others would consider it both process and outcome. Still others, pointing
to the variety of ways “process” and “outcome” are used and to some of
the problems with the traditional distinction (Shapiro et al. 1994; Stiles et
al. 1994), argue that the distinction is problematic.
I use “process” and “outcome” as terms of art, neither distinguishing
them sharply nor intending by their use the assumptions Stiles, Shapiro,
and Harper (1994) properly critique. An ethical evaluation of some
dimensions of therapy, like “Bob’s accepting greater responsibility for his
actions,” does not depend on “correctly” labeling it process, outcome,
both, or neither. A rough distinction can be drawn, however: some
ethical issues pertain to the goodness, rightness, or virtue of particular
therapy goals or outcomes. They will be discussed in the next chapter.
Other ethical issues have to do with what occurs during therapy
regardless of therapy goals. For example, however we ethically evaluate
particular therapy goals, we can consider the rightness of Dr Peterson’s
violating Bob’s confidentiality, the goodness of his treating Bob with
respect, or whether Dr Peterson’s fairness (his consistently acting justly)
is virtuous. Those ethical judgments all pertain to process, and can be
made without reference to therapy goals. It is those process-dimensions of
therapy, and some that either overlap with outcome or transcend the
distinction, that I will address in this chapter.
By an ethical evaluation of psychotherapy processes, I mean thinking
about process in terms of what is good, right, and/or virtuous. In this
chapter, I will first discuss in general how ethical considerations are
relevant to a variety of dimensions of therapy process and to professional
standards and ideals. In the second half of the chapter, I will address some
specific dimensions of therapy process, like therapist influence on client
values.
A variety of ethically relevant dimensions of therapy process can be
distinguished. Some pertain to therapy in general, regardless of
therapeutic content. For instance, we might assert that it is good that Dr
Peterson treats Bob with respect, whatever issues he brings to therapy.
Other types of ethically relevant therapy process pertain to how
therapists and clients address specifically ethical issues. For instance, we
can ethically evaluate the kind of influence Dr Peterson exerts on Bob’s
moral convictions. We may think it wrong for Dr Peterson to exert strong
pressure on Bob to adopt a “Me-first” philosophy of life and abandon his
sense of moral obligation to his three children. Dr Peterson may,
however, legitimately explore with Bob whether he wants to hold that
152 ETHICS AND VALUES IN PSYCHOTHERAPY
sense of obligation more flexibly or balance it with other ideals in a
different way. In making the assertion that Dr Peterson’s influence on
Bob was wrong, we ethically evaluate the manner (process) of Dr
Peterson’s influence on Bob’s ethical convictions.
A full-fledged ethical evaluation of therapy process addresses topics
like what it means to be a good therapist (e.g. warmth, timing, empathy,
use of effective techniques, and “therapist virtues”) and which methods,
techniques, and interpersonal qualities are good, right, and/or virtuous
(e.g. those that match clients’ needs, are effective,1 are carried out in
accord with the theory to which they correspond, respect the client’s
autonomy, and so forth). And so we can assert that it was good that Dr
Peterson listened carefully to Bob and right that he preserved Bob’s
confidentiality. It was not good that he implicitly promised Bob
“objective” therapy and wrong that he planned to lie to (and defraud)
Bob’s managed care company to insure ample coverage.
Diagnosis can be included as well because, as Fulford suggested,
diagnosis “can be thought of essentially as deciding what is wrong with
someone” (Fulford 1989:167). And that, of course, requires a normative
sense of some good state from which the person’s symptoms deviate, or
distinguishing what is wrong with a person (their nonmorally or morally
bad state) from what is right with that person.
To clarify further the relevance of ethics to the processes of therapy, I
would like to discuss from several perspectives how basic ethical
principles and virtues, as discussed in Chapter 4, pertain to therapy
processes.
Ethical principles and virtues applied to therapy
processes
If, when making an ethical judgment about a particular therapeutic
technique or method, someone looks solely at its consequences, ends, or
goals, that person is using a teleological or consequentialist theory.
Outcome is used to determine whether a particular therapy process is
good, right, or virtuous. Those who argue that therapists should
exclusively employ techniques that have been empirically supported or
validated as effective (effective in reaching some specified good outcome)
thus tend to be ethical teleologists.
Others employ principles in making ethical judgments about process
(and so use deontological ethical theories). They can consider outcome
when thinking about the goodness or rightness of a therapeutic
technique, but also use other criteria. Meara, Schmidt, and Day (1996) set
forth six basic ethical principles, or criteria, to be used in ethical decisionmaking:2 respect for autonomy, nonmaleficence (avoiding harm),
beneficence, justice, fidelity, and veracity.
Those six principles can be applied to the processes of any therapeutic
relationship, for example, Dr Peterson’s therapy with Bob. On one level,
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 153
Dr Peterson did not show sufficiently high levels of respect for Bob’s
autonomy because he did not accept Bob’s stated goals for therapy and
(more significantly) because he did not negotiate with him to develop a
richer understanding of how Bob could use therapy (richer than Dr
Peterson telling him what to do). On the other hand, Dr Peterson did not
reduce Bob’s autonomy by telling him what to do. He wanted to improve
Bob’s ability to make a decision about his marriage by removing
psychological impediments that prevented the full expression of his
autonomy. And so he exhibited respect for Bob’s autonomy.
Dr Peterson did nothing that would obviously harm Bob
(nonmaleficence) and appeared to be engaged in a process of therapy
that could benefit Bob (beneficence). However, their deep, unspoken
disagreement about goals (desired outcomes) for therapy—Dr Peterson’s
insight and autonomy versus Bob’s knowing what to do about his
marriage and symptom relief—is troublesome. Unless that is resolved,
Bob is unlikely to continue in therapy, and may either be harmed (by not
seeking a therapist in the future because of his negative experience with
Dr Peterson) or simply not benefit from his session(s) with Dr Peterson.
Dr Peterson showed a high level of fidelity to Bob.
Thinking about the relationship of Bob and Dr Peterson in terms of
justice will not tell us much—if we focus only on the micro-level. But if we
expand to the macro-level and think about society as a whole, Dr
Peterson’s exaggerating Bob’s problems to obtain more sessions from his
managed care company is clearly wrong (in addition to being illegal).
Given a limited pool of money to provide mental health care for a group
of people (the present reality for many people covered by some
government and managed care plans), Dr Peterson’s lying about the
seriousness of Bob’s problems to obtain more sessions for him may be
unjust to other patients whose need for sessions is greater because it may
prevent them from receiving needed therapy sessions (Austad 1996).
In submitting a fraudulent assessment of Bob to the managed care
company, Dr Peterson is also not being truthful (he is lacking in
veracity). Truth-telling, by therapist and by client, is arguably essential to
therapy, whether truth is understood in terms of objectivity or
plausibility (Frank and Frank 1991), of science or hermeneutics, as
historical truth, or as narrative truth (Spence 1982). Ideal clients speak
truthfully, striving to know the truth about themselves, however
uncomfortable that may make them. Ridding ourselves of pleasant selfdelusions, courageous self-scrutiny, and an honest view of ourselves
were ideals shared by Nietzsche and Freud, ideals that have profoundly
influenced how many understand the processes of therapy.
Adherence to important ethical principles should set therapists apart
from other people, argues Kitwood. He contends that, “in its
uncompromising regard for personhood and its resolute pursuit of
psychological truth,” a therapeutic relationship “has moral qualities that
are conspicuously lacking in the everyday world” (Kitwood 1990:202).
Therapy process can also be understood in terms of the virtues (stable
ethical characteristics) possessed by therapists and clients (Graber
154 ETHICS AND VALUES IN PSYCHOTHERAPY
and Thomasma 1989). Doherty (1995), for instance, argued that therapists
ought to embody three virtues: caring, courage, and prudence.3
To apply a virtue ethics perspective to Dr Peterson, we can ask, for
instance, whether he lacked courage. We could argue that he lacked that
virtue because he failed to tell Bob that his desire for simple answers was
unrealistic and because he failed to risk a conversation with Bob about
goals that could have resulted either in a more nuanced therapeutic goal
or in Bob not returning for a second session. Lack of courage may also
have been evident in Dr Peterson’s failure to communicate honestly with
Bob’s managed care company about the nature of his problems.
Prudence is, I think, an especially important ethical virtue for the
therapist. Doherty defines it as “good judgment or, in the words of
Merriam-Webster, ‘a quality in a person that allows [him or her] to choose
a sensible course of action.’ Common sense, if you will, backed up by
wisdom” (Doherty 1995:163). This virtue, which I prefer to label “practical
wisdom,” is seen in people who regularly make wise decisions about
difficult matters in complex circumstances. In contrast to Dr Peterson, for
instance, a prudent therapist should know that many working class
males seeking therapy want symptom relief and practical answers.
Helping Bob develop a more nuanced understanding of therapy would
therefore likely require building upon those desires.
Meara, Schmidt, and Day link prudence to ethical rules and principles,
suggesting that “those who are prudent know what rules or principles
might apply and whether they should be applied in a particular instance”
(Meara et al. 1996:39). But MacIntyre points out that Aristotle rarely
referred to rules. Rather, Aristotle held that those who exemplify the
virtues exhibit “a capacity to judge and to do the right thing in the right
place at the right time in the right way” (MacIntyre 1984:150). The same
difference is present among therapists: some, in asserting that therapists
should use only those techniques that have been empirically validated,
argue for a rule-based prudential practice of therapy; others argue that
the wisdom therapists ideally exhibit cannot be reduced to the
application of rules, whether science-based or not.
Therapy processes in ethical perspective
In discussing therapy process and ethics, I began with ethical categories
and applied those categories to therapy processes. I now want to do the
reverse: to begin with how therapists and therapy researchers discuss
process and then ask ethical questions. That is, I will look at therapy
processes (e.g. techniques) from an ethical perspective, discerning the
ethical convictions (morals) underlying or implied by those processes,
because as London suggested, “morals are implied by techniques”
(London 1964:165).
Therapy researchers have identified a wide range of therapy
processes (Elliott 1991; Frank and Frank 1991; Kubacki and Gluck 1993;
Mahoney 1991; Orlinsky et al. 1994; Prochaska and DiClemente 1994).
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 155
Although their intent was primarily descriptive, the processes they have
isolated have prescriptive dimensions.
To the extent that certain therapy processes produce more positive
outcomes (i.e. “good” outcomes) than other therapy processes, we can
claim that it is good, and perhaps even right or obligatory, for therapists
to employ those processes. The exhaustive review by Orlinsky, Grawe,
and Parks (1994) of the relationship between process and outcome
variables found that some process variables were, in fact, tied more
closely to outcome than others. Process variables robustly linked to
outcome included therapeutic bond or alliance, patient cooperativeness,
patient expressiveness, and paradoxical intention techniques. From an
ethical perspective, the link between paradoxical intention techniques
and positive therapy outcome is particularly interesting because
therapists using those techniques are, if not overtly dishonest, at least less
than fully honest. One ethical principle, truth-telling, is in conflict with
another, maximizing client well-being.
Of particular relevance to Dr Peterson’s work with Bob, Orlinsky,
Grawe, and Parks (1994) found that clarity and consensus about
expectations and goals for therapy tend to be important factors in therapy
outcome, from the client’s perspective and when measured by objective
indices, but not from the perspective of therapists. This suggests that Dr
Peterson should (is obligated to, if he wishes to maximize the chances
Bob will improve) work with Bob to clarify goals and expectations, and
develop a consensus.
In contrast to the conclusion drawn by Orlinsky, Grawe, and Parks
(1994), Shapiro, Harper, Startup, Reynolds, Bird, and Suokas (1994) and
Lambert (1989) found little relationship between process variables (like
techniques) and outcome.4 The Shapiro group conducted a meta-analysis
of studies examining the process-outcome relation in thirty-three research
publications and found an average effect size that accounted for less than
2 percent of the variance in outcome. Lambert reported that only 1.9
percent of the variance in therapy outcome in four studies could be
accounted for by variations in therapeutic technique. He suggested that
researchers pay greater attention to differences among therapists, rather
than among techniques, because research findings indicate that some
therapists are better than others, and we need to understand how and
why that is the case. To the extent that outcome is not related to therapy
techniques (Beutler 1995, Norcross 1995, and others dispute that
conclusion), however, an ethical analysis of therapy process should be
concerned primarily with the intrinsic goodness, rightness, or virtue of
various therapy processes (process unrelated to outcome), rather than
emphasizing the ethical status of techniques based on their relationship
to outcome.
One approach to understanding therapy process that has received
empirical support is that of Prochaska and DiClemente (1994) and
colleagues (Fava et al. 1995; Prochaska et al. 1992). They have isolated five
general categories of change process, with two subtypes for each based
on whether the change process generates change experientially
156 ETHICS AND VALUES IN PSYCHOTHERAPY
(internally) or environmentally (externally). These change processes are
conceptualized at an intermediate level of abstraction, being more
abstract than techniques, but less abstract than theoretical frameworks
(Prochaska and Norcross 1994).
To illustrate how therapy change processes can be evaluated ethically,
I will discuss how five change processes (representing either subtype of
all five general categories of change processes) involve issues that can be
evaluated ethically.
Education is a change process that can produce a variety of changes in
clients. Since education is not value-free, the content and manner of
education can be evaluated ethically. Depending on one’s ethical
perspective, different ethical evaluations would .be made if Dr Peterson
emphasized educating Bob about the dangers to his health of not
expressing his anger directly than if he emphasized the possible harmful
effects of divorce on Bob’s children. Likewise, ethical evaluations would
vary depending on whether Bob was educated about the benefits of longterm therapy or about the benefits of self-help groups. Corrective
Emotional Experiences are believed to play a role in producing change.
Would it be best for Dr Peterson to facilitate experiences in which Bob is
likely to feel emancipated from the parental and marital responsibilities
with which he is burdened? Or experiences through which he feels
empowered to face his existing commitments with new determination?
Self-liberation increases the autonomy that many in the West think the
summum bonum (greatest good). Some ethical analyses of this change
process are not likely to be controversial, for example, the goodness of
freedom from severe mental illness, marked psychological distress,
unresolved emotional burdens, or ineffective thinking that prevents Bob
from making decisions. More controversial is the question, “Freedom for
what?” (Tjeltveit 1989). Would it be ideal for Bob to be free to take better
care of himself? free to make a decision about his marriage? free from the
parental and marital burdens that cause him emotional distress? A sole
focus on freedom thus fails to address the relationship between Bob’s
freedom and what he sees to be obligations to his children and, to a lesser
extent, to his wife. Counterconditioning, a change process involving
changing responses to stimuli, may be viewed in a positive light if Bob
develops new, more adaptive responses to the stimuli of anger and
loneliness that are now leading him to drunkenness. But
counterconditioning may be viewed negatively if he develops
maladaptive responses to the stressful stimuli in his life. Finally,
Reevaluation, changes in internal consequences, can be viewed in positive
ethical light (e.g. if Bob learns to reinforce himself when making good
changes and carrying out his responsibilities without undue distress), but
in a negative light (e.g. if he learns to manipulate his wife and neglect his
children by reinforcing himself only when acting to meet his own
needs).
As a general rule, change processes at an intermediate level of
abstractness are, by themselves, neither good nor bad, right nor wrong.
But when translated into action in a specific context, in a particular
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 157
therapeutic relationship, their ethical character becomes evident. This
underscores a point made by Elliott and Anderson (1994), Hill (1994),
Orlinsky, Grawe, and Parks (1994) and by Stiles, Shapiro, and Harper
(1994): context matters when we look at therapy process. For example, to
ethically evaluate an intervention, we need to know its context because
that can significantly affect the intervention’s impact on a client. A
therapist’s pointed confrontation of a client with good ego strength in the
context of an established therapeutic relationship may be very effective,
but devastating to a fragile client in the early stages of therapy. One
intervention; two outcomes, depending on context.
To avoid oversimplifying therapy processes, researchers suggest that
more complex models of therapy process be developed (Elliott 1991; Elliott
and Anderson 1994; Heatherton and Weinberger 1994; Orlinsky et al.
1994; Stiles et al. 1994). If ethical evaluations of therapy process are to be
done well, they should be no less complex.
Finally, to address the changes in the meanings clients and therapists
employ to understand therapy and human life, Frank and Frank (1991)
and others have suggested that hermeneutic, rather than scientific,
methods be used. And Browning (1987), Cushman (1993, 1995),
Richardson and Woolfolk (1994), and others have used hermeneutic
approaches to ethically evaluate therapy processes.
Ethical underpinnings of professional standards and
ethics
We can explore the relationship between therapy process and ethics in
another general way: an analysis of the ethical assumptions contained
within professional standards and ideals. Professional standards of
practice, taught in supervision and course work, imply ideas about what
is good, right, and virtuous in therapy. Dr Peterson’s decision to obtain
further information from Bob rather than immediately answering his
question about forgiving his wife is consistent with professional standards,
and thus considered good.
Professional codes of ethics set forth both minimal ethical standards
concerning the processes of therapy (e.g. no sex with clients) and
aspirational standards (what occurs in therapy under ideal circumstances).
APAs ethics code, for example, states that psychologists “apply and make
public their knowledge of psychology in order to contribute to human
welfare” (APA 1992:1600). Some ethical assumptions emerge only from a
careful analysis of ethics codes. “Implicit in the ethical codes,” point out
Hare-Mustin, Marecek, Kaplan, and Liss-Levinson (1979:3), “is a model
for the client-therapist relationship that fosters the goals of mental
health.”
But we can also understand the ethical character of therapy process by
distinguishing what exceptional therapists do in therapy from what the
merely competent do. The aspirational elements of the ethics codes of
158 ETHICS AND VALUES IN PSYCHOTHERAPY
APA (1992) and other professional associations capture this, in part. The
highest levels of ethical excellence, found in outstanding therapists, go
well beyond what codes can spell out, however. The ethical question we
need to address is this: what therapy processes distinguish average
therapists from those who are exceptional? What sets apart the merely
competent therapist from the therapist who addresses the ethical
dimensions of psychotherapy processes in a way that is outstanding?
Some key, ethically relevant dimensions of therapy
process
Because some aspects of therapy process are particularly pertinent to an
ethical analysis of psychotherapy, I will focus on them in more depth. I will
consider seven conceptually overlapping facets of the process of
psychotherapy.
Agreements about particular therapeutic relationships
Bob entered psychotherapy with certain assumptions: Dr Peterson would
help him, would tell him what to do about his marriage, and would
never tell anyone what he said in the session.
Dr Peterson had a different set of assumptions. The most effective
therapeutic approach is generally short-term dynamic therapy. Resolving
clients’ unconscious conflicts, conflicts that are rooted in their childhoods
and responsible for their presenting problems, reduces the problems that
lead them to seek treatment and increases their autonomy. (And so Bob
would be able to make up his own mind about his marriage.) If Bob’s
managed care company required information about Bob of the type
usually provided to managed care companies, Dr Peterson would
provide it. If ever served a valid subpoena by a properly constituted legal
authority, he would divulge whatever he was ordered to reveal about
Bob. Dr Peterson also assumed that marital affairs are quite common.
Furthermore, he considered one of Freud’s most profound (yet curiously
neglected) observations to be: “The cure for nervous illness arising from
marriage would be marital unfaithfulness” (Freud 1959:195). Dr
Peterson’s own “infidelity cure” (Wallace 1986:104) had reinforced that
belief, and he congratulated himself on no longer being “tyrannized by
shoulds” about it, in contrast to his ex-wife, whose “rigid” moral beliefs
and unwillingness to forget about his affairs produced, he believed, the
demise of their marriage. In that and similar cases, he assumed, the
problem was the partner’s overactive superego (seen in “moralistic”
beliefs like “thou shalt not commit adultery”) rather than the affair
itself. Accordingly, he thought it would be helpful for Bob to see (to be
converted to his view) that Bob’s s own happiness, rather than outdated
societal ideals about marital relationships, should be paramount in his
decision-making. He assumed Bob would eventually adopt this view, if
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 159
truly committed to becoming mentally healthy. But since he believed a
therapist’s values should be “opaque” to the client, Dr Peterson did not
divulge those psychological/ethical convictions to Bob.
About more concrete dimensions of the therapeutic contract (e.g. the
first session would last fifty minutes), Dr Peterson and Bob agreed.
Neither Bob nor Dr Peterson explicitly thought of therapy as an ethical
endeavor, yet both made assumptions pertaining to ethical issues. And
therapy clearly addressed ethical issues. Their agreement and
expectations about the ethical dimensions of therapy were therefore
implicit.
In general, agreements between therapists and clients are ethically
relevant for several reasons. Agreements about therapy can either
preserve client autonomy (if agreements are mutual) or reduce it (if
determined by therapists unilaterally). Agreements about therapy
generally assume that the therapist will exhibit fidelity to the client and
make the best interests of the client foremost (beneficence). The kinds of
relationships therapists and clients establish, sometimes discussed in
ethical terms (see discussion below), develop in part because of therapist
and client agreements about therapy. Because of this, Ramsey argued
against the use of “contract,” the traditional term used to describe
agreements between therapists and clients. The legal and business
connotations of the term do not capture the ethical core of therapy
relationships, properly understood, he asserted. And so “‘partnership’ is
a better term…than ‘contract.’ ‘Joint adventurers’…is better still. The
concept is one of an ongoing partnership established by an
understanding consent, sustained by present continued consent and
terminated by voluntary dissent” (Ramsey 1971:705). But, as discussed in
Chapter 7, agreements about therapy are increasingly not agreements
between therapist and client alone, but between therapist, client, and
third-party payer. And therapists have criticized third-party payers for
failing to be clear about their assumptions about “acceptable” therapy
goals and for using unduly restrictive criteria for therapy goals. It is also
difficult to negotiate an agreement about a particular therapeutic
relationship when one can only communicate with one of the parties, the
one holding the purse strings, by calling a toll-free number and leaving a
voicemail message. Nevertheless, I think it imperative that all
stakeholders work together to develop an agreement about a particular
therapeutic relationship.
Agreements about therapy are also made about other dimensions of
therapy, especially therapy goals. If, as I will argue in Chapter 9, goals are
value-laden, the process by which goals are established is a vitally
important ethical task. Furthermore, the therapeutic bond (a dimension
of therapy process empirically linked to outcome) may stem in part from
therapists’ and clients’ “normative conceptions of how they ought to
relate to each other” (Orlinsky et al. 1994:363), that is, to their
understanding of the therapeutic contract.
The implicit understanding about therapy in most societies is that it is
value-free. And so the implicit agreement between therapist and clients is
160 ETHICS AND VALUES IN PSYCHOTHERAPY
generally that therapy will be value-free. Because therapy is not, the
ethical character of therapy is poorly addressed in those agreements, a
serious problem to which I will return in Chapters 10 and 11.
Finally, agreements about therapy have to do with informed consent
(Braaten et al. 1993; Dyer and Bloch 1987; Faden and Beauchamp 1986;
Lidz et al. 1984; Tjeltveit 1986). Informed consent is a legal and ethical
concept referring to the obligation of professionals to provide clients with
information of relevance to them about a professional relationship, such
as a treatment’s goals, procedures, possible benefits and side effects, and
alternatives. Clients then either agree to participate in (consent to)
therapy or not. By insuring that clients are knowledgeable about therapy,
the process of obtaining informed consent protects their rights and
autonomy.
Dr Peterson’s failure to inform Bob of the limits of confidentiality meant
that Bob did not give truly informed consent to therapy. This could harm
Bob. Learning that Dr Peterson has discussed his case with his managed
care company or must testify at a custody hearing, for example, could
destroy his trust in Dr Peterson.
More generally, therapists like Dr Peterson who imply or state that
therapy is value-free (“objective”) provide false information about
psychotherapy and prevent clients from giving adequately informed
consent. In a manner and to an extent appropriate to a particular
therapeutic relationship, therapists need to provide clients with
information about its ethical dimensions, including possible value
conflicts between therapists and clients (Berger 1982). Since this
implication of therapy’s ethics-laden character has important
ramifications for professional ethics, I will discuss it further in
Chapter 11.
Some, like Dr Peterson, argue that therapists ought to keep silent about
their own values, because explicitness may hurt transference, may make
it more likely that clients—eager to please therapists who are seen as
powerful authority figures—will “adopt” therapist values, or both. But
Frank and Frank (1991) argued that explicit denials that therapists
influence client values (like Dr Peterson’s claim that therapists are
“objective”) might magnify the therapist’s influence on clients.
By way of contrast, feminist therapists (Feminist Therapy Institute
1990), explicitly religious therapists (e.g. Jensen and Bergin 1988), and
others have argued that therapists should be explicit about their ethical
convictions. As the Feminist Therapy Institute Code of Ethics states,
“feminist therapists recognize that their values influence the therapeutic
process and clarify with clients the nature and effect of those values”
(Feminist Therapy Institute 1990:38). Doing so makes truly informed
consent possible. And if clients know their therapist’s values, therapists
are less likely to have an untoward influence on client values.
Other challenging ethical issues are raised by the informed consent
process. The autonomy of some clients is so impaired they are unable to
consent to therapy. Ironically, they may need therapy to develop the
level of autonomy required to give fully informed consent to therapy, or
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 161
to engage in a fruitful discussion about the role of values in a therapeutic
relationship. As Lowe noted, “often the client is so bewildered and
confused that he {or she} can not clearly focus his [or her] values” (Lowe
1976:220).
Particularly challenging to many therapists and clients is informed
consent about ethical issues tied to religious convictions. Lovinger noted
that religious clients, fearful of being coerced into altering their religious
or ethical beliefs, may want information about their therapist’s religious
beliefs. But many therapists think those beliefs private, think disclosure
of them damages therapeutic relationships, or both. Lovinger’s solution:
to indicate my orientation briefly and state that I have no interest in
having other people see it my way. If their religion is important to
my patients, then I would certainly be interested in understanding
it, as I am interested in anything they would want to tell me.
(Lovinger 1984:69)
That would no doubt be effective in many cases. But some clients may
interpret “I have no interest in having other people see it my way” to
mean the therapist is committed to an ethical relativism conflicting with
the client’s convictions.
Discerning the nature and extent of the information to be provided to
particular clients and handling the process of obtaining informed consent
are difficult tasks. Suppose Dr Peterson discloses his “sole” value as a
therapist: “insuring that my clients are happy.” Is he also obligated to spell
out its corollary—“and so my concern about your children and marriage
is limited to whether or not they contribute to your happiness”—
convictions that are at odds with Bob’s values? Problems can also arise
when therapists provide clients with excessive, irrelevant, or overly
complex information. As Handelsman, Kemper, Kesson-Craig, McLain,
and Johnsrud (1986) note, even those who use informed consent forms
often fail to present information of interest to prospective clients or use
language at a reading level higher than that possessed by the average
client. And Margolin (1982) points out that providing too much
information about therapy may (falsely) persuade a client that the
therapist does not really want to work with him or her. Furthermore,
short-term therapy provides very little time for detailed discussions
about the nature of therapy. A variety of ethical considerations needs to
be taken into account (Tjeltveit 1986), with practical wisdom required to
handle agreements about therapy optimally.
Preserving and enhancing client autonomy
Therapy processes that deny, restrict, or minimize the autonomy of
clients are generally regarded (at least in many Western ethical
162 ETHICS AND VALUES IN PSYCHOTHERAPY
traditions) as not good or unethical. Good therapy processes, by way of
contrast, preserve and enhance client autonomy.
And so behaviorism has been criticized, Macklin notes, because its
techniques “may ignore or violate autonomy.” In fact, some think
autonomy so important that if therapists reduce autonomy, therapeutic
effectiveness “is not a morally relevant consideration” (Macklin 1982:36).
From this Kantian perspective, therapy process (preserving autonomy) is
the primary ethical consideration; therapy outcome (effectively reaching
therapy’s good goals or outcomes) becomes relevant only when client
autonomy is fully preserved.
Some of the outrage about managed care in the US may arise when
those who consider autonomy to be the chief (or only) ethical
consideration encounter managed care entities that are perceived to
regard effectiveness to be the chief (or only) criterion for making
decisions. For the former, the latter’s abridgment of client (and therapist)
autonomy is unconscionable.
The pernicious falsehood that therapists are either value-free
(upholding client autonomy) or impose their values on clients
(eliminating client autonomy) stems in part from particular
understandings of “autonomy”: autonomy, the possession and right of the
self-contained individual, is opposed to authority. Ethical convictions
(other than autonomy) necessarily stem entirely, it is believed, from
authority, which we should profoundly distrust, because it compromises
our ethical freedom (Richardson 1989).
Ethical convictions other than freedom also motivate those in the West,
however. For example, Macklin notes that “we also think it is a good
thing to promote people’s well-being and to prevent unnecessary harm
from befalling them” (Macklin 1982:5; see Taylor’s 1989 discussion of
benevolence). Richardson also documents how therapists who employ a
variety of approaches implicitly hold ethical ideals, but explicitly espouse
only an uncompromising devotion to autonomy. As a result, he argues,
“modern therapeutic wisdom does not represent a clear alternative to
traditional belief or rootless modern freedom so much as an enticing but
ultimately confused and unsatisfactory blend of the two” (Richardson
1989:317).
Non-Westerners, as noted earlier, are less likely to valorize autonomy,
and more likely to consider it as but one of many ethical ideals. And
Westerners are beginning to adopt, or reclaim, positions that affirm
autonomy and other ethical convictions, but without radically
dichotomizing them. For example, Richardson observes that hermeneutic
perspectives seek “to recapture something of a premodern sense of
belonging and indebtedness to larger realities while preserving
undiminished our modern critique of arbitrary authority” (Richardson
1989:318). And Doherty, who argues for ethical ideals in addition to
autonomy, maintains that “the central safeguard for keeping moral
consultation from becoming prescriptive and coercive is maintaining
respect for the moral agency of the client” (Doherty 1995:65).
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 163
The quality of the therapist-client relationship and
therapist treatment of clients
Another ethical element of therapy process is the therapeutic relationship.
Psychotherapy, Bickhard asserts:
is not just an activity to which ethical considerations can be applied,
nor just an activity which makes use of moral considerations in
selecting its instrumental goals. Psychotherapy is a very special kind
of intrinsically ethical relating to another person.
(Bickhard 1989:163)
Advocates of this and related ethical stances assert that therapy
relationships should be non-manipulative; participants ought not to use
one another to reach some desired end. Relationships between therapists
and clients should not be I-It relationships, to use Buber’s (1970) term, in
which therapists relate to clients as if clients are objects. Rather,
relationships between therapists and clients should be I-Thou
relationships, characterized by a profound intimacy between persons.
For those and other reasons, how clients are treated is considered by
many to be an ethically vital aspect of therapy process. The good therapist
treats clients with respect, sensitivity, and genuine caring. Indeed, argues
Kitwood, therapeutic relationships have “moral qualities that are
conspicuously lacking in the everyday world” (Kitwood 1990:202).
In apparent contrast, Freud described the therapist as a surgeon “who
puts aside all his feelings, even his human sympathy” (Freud 1958:115).
He argued that that “emotional coldness” protects the doctor’s own
emotional life and helps the client. The ends (outcomes) of client health
and therapeutic effectiveness thus justify the means (process) of
emotional coldness.
But ethical analyses of therapy diverge at precisely this point. Do ends
justify means? Does positive outcome justify any process? Freud appears
to have thought so (at least at times). And critics of those who stress
outcome studies as the sole criterion for determining therapist actions
assert they do as well.
Others, however, argue that clients are to be treated as persons of
intrinsic worth. Accordingly, we can never justify positive outcomes if
achieving them requires us to treat persons as objects or merely as means
to an end. And so therapists should always treat clients as persons, as
valuable in and of themselves. Therapeutic processes are thus ethically
relevant, whatever their relationship to outcome. (It is, of course, also
possible to be concerned about therapeutic effectiveness, as evaluated by
empirical research, and to treat clients as persons of intrinsic worth.)
Pragmatism, materialism, emotivism, positivism, and a strictly
business perspective on therapy have all been criticized for contributing
to therapists failing to take seriously the personhood of therapy clients
164 ETHICS AND VALUES IN PSYCHOTHERAPY
and to therapists treating clients as less than fully human or as means to
some end. “Object” relations theory can also be criticized for referring to
significant persons in a client’s life as “objects” rather than as persons.
Positivistic views, argues Bickhard (1989), fail to take seriously humans
as ethical beings. And MacIntyre argued that the ethical theory of
emotivism (see Chapter 4 above), closely tied historically to positivism,
entails “the obliteration of any genuine distinction between manipulative
and non-manipulative ends” (MacIntyre 1984:23). Therapists whose de
facto ethical theory is emotivism and whose sole concern is positive
therapeutic outcome thus have no reason to refrain from manipulating
and using others—if doing so helps them reach their goals. Those who
reject such a view are drawing upon richer ethical sources, sources
asserting that how therapists treat clients is important ethically.
Ethical dialogue
“Psychotherapy as moral discourse” or “ethical dialogue” can mean
either a description of therapy as an inescapably ethical activity or an
ethical ideal about ethical conversations in therapy. (The two connotations
are often blurred.) As description, “moral discourse” refers to a wide
range of implicit and explicit communications about ethical issues taking
place in the structures, concepts, and practices of individual therapists
and clients, communities, and cultures (Cushman 1995; Doherty 1995;
Nicholas 1994). The ethical ideas embedded in cultures, communities,
and professions shape therapy in so many ways—ways often invisible to
its participants—that therapists and clients often discuss ethical issues
without being aware they are doing so.
Therapists and clients alike function as ethicists in a therapeutic
relationship. That is, both reflect on, have convictions about, and/or
attempt to influence the other about ethical questions and issues. The
result is, or should be, dialogue, a dimension of psychotherapy
sometimes overt, but more often understated and implicit. Furthermore,
other psychotherapy stakeholders participate in the dialogue about
ethical dimensions of therapy as well, especially family members and
third-party payers.
When the terms “moral discourse” or “ethical dialogue” are used to
refer to ethical ideals, they refer to the quality of the discussions between
therapist and client about ethical matters. “Dialogue” connotes
conversations characterized by these valued (“good”) qualities:
collaboration (Bergin 1991), negotiation (Aponte 1985), openmindedness, serious attempts to listen to and understand one another,
open-ended exchanges, a willingness to reconsider one’s position, give
and take, and respect for one another. Ethical issues are explored,
Doherty argues:
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 165
in the heart of the therapeutic dialogue, in conversations in which
the therapist listens, reflects, acknowledges, questions, probes, and
challenges—and in which the client is free to do the same and to
develop a more integrated set of moral sensibilities.
(Doherty 1995:37)
This kind of conversation occurs, if not between equals then between two
responsible, competent parties. It will ideally not be implicit or
authoritarian. Therapists will not falsely claim neutrality. Tradition and
precedent will count less in therapeutic negotiations about values than
debate and discussion (Aponte 1985). Finally, in applying Habermas’s
theory of communicative action to therapy, Kubacki noted that ethical
dialogues in therapy are ideally characterized by “the right to dissent or
capacity for choice” (Kubacki 1994:469) and by participants who are
motivated to reach consensus or solve problems.
I think ethical dialogue exemplifying those ideals is very important.
Indeed, one reason I am writing this book is to foster such ethical dialogue.
I do not write as if claiming any final answers. And I am surely neither
value-free nor able to impose my values on my readers. I hope, rather,
that this book is part of, and will help spawn, an increasingly
sophisticated and adequate ethical dialogue about the ethical character of
therapy, dialogue among therapists and other therapy stakeholders, and
dialogue between therapists and clients.
But Aponte reminds us that, however beneficial dialogue between
therapist and client may be, such dialogue is not, finally, between equals.
Therapists possess more power than clients, and hence greater moral
leverage. He notes that “such leverage places on the therapist the
responsibility of certain ethical concerns: what values to communicate
and how to exert his [or her] influence” (Aponte 1985:328). It is to that
central but thorny ethical dimension of therapy process that I now turn.
Therapist influence on the ethical dimensions of clients’
lives
Therapy may ethically transform Bob. The ways in which Dr Peterson,
other therapists, and other aspects of therapy exert ethical influence on
clients can be both described and evaluated. In this section, I do both.
Types of influence
A variety of therapy processes can change the ethical dimensions of a
client’s life. This is partly because so many human characteristics—
values, attitudes, cognitions, emotions, behaviors, choices, motivation,
identity, locus of control, personality, ethical perceptiveness, learning,
social cognition, interpersonal relations, and so forth—are relevant, at
166 ETHICS AND VALUES IN PSYCHOTHERAPY
least in part, to what is good, right, and/or virtuous. And those
characteristics can be understood from the perspective of any of
psychology’s corresponding subspecialties. And all can be altered in
therapy.
The different kinds of relationships that therapists establish with
clients can result in different types and degrees of influence on clients. As
Weisskopf-Joelson notes:
therapists range all the way from pure “gardeners”—who view
their clients as an appleseed which can grow into the best apple tree
through loving care but cannot become a pear tree—to Pygmalions
who desire to shape their clients according to an ideal image based
on their own value system.
(Weisskopf-Joelson 1980:462)
Each of the following words (with distinguishable but sometimes
overlapping meanings) can characterize influential moments within a
therapeutic relationship: educative, advisory, healing, coercive,
persuasive, transforming, emancipatory, actualizing, pastoral, priestly,
prophetic, exhortative, judging, supportive, authoritative, corrective, and
authoritarian. With the exception of the last two, all occupy some portion
of the middle ground between relationships that are value-free and
relationships in which therapists impose values on clients.
As a result of therapy’s influence, client values can be, to use Rescher’s
(1969) taxonomy, acquired and abandoned, redistributed, emphasized
and de-emphasized, rescaled, redeployed, restandardized, retargeted,
and upgraded or downgraded. And R.M.Williams (1979) suggested that
values can be created, abruptly destroyed, attenuated, extended,
elaborated, specified, limited, explicated, made more or less consistent,
and experienced more or less intensely. Client behaviors and ethical
theories may also be affected in those ways. Other effects on clients have
been postulated. Schwehn and Schau (1990) documented, for example,
how therapy stabilizes some client values. And B.E.Wolfe (1978)
suggested that clients shift their locus of moral authority from sources
that are external to those that are internal.
Changes in the ethical dimensions of clients’ lives may stem from a
variety of processes. Some ethical changes may be side effects of the
positive psychological changes clients make. Others may be unintended
side effects of the influence processes therapists employ. And still other
changes may be the result of intentional efforts by therapists to change
some ethical dimension of clients’ lives. As Wallerstein notes, some of the
pressures therapists exert on clients are “deliberate and avowed, some of
them unrecognized and unavowed, some unrecognizable because buried
within the framework of the very assumptions upon which the whole
endeavour rests” (Wallerstein 1976: 371).
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 167
Ethical changes can stem in several ways from the positive
psychological changes clients make. Because clients grow, eliminate
maladaptive behaviors, employ more adaptive cognitions, develop new
identities, have new experiences in therapy (or as a result of therapy), and
gain insight, they sometimes reevaluate old ethical positions and
behaviors, make new decisions, and move in different life directions.
Clients whose lives used to center around psychological problems, either
because of the severity of their problems or as a symptom of their
problems, find they have new energy to devote to ethical concerns once
they make progress in therapy. And finally, of particular importance,
clients often develop greater autonomy. As Engelhardt argued,
psychotherapy sets “the stage for the possibility of ethical decisions” by
freeing clients “from the control of unconscious drives and
unacknowledged forces” (Engelhardt 1973:441). And so clients are free, in
new ways, to make ethical decisions and to act ethically.
The persuasive processes of psychotherapy, intended to address issues
in clients’ lives that are psychological, may also affect issues that are ethical.
For example, Dr Peterson may target Bob’s depression by gently
challenging his belief that he “should” remain committed to his wife
because he promised God, his wife, his family, and his friends that he
would do so; Dr Peterson’s persuasive abilities may change both Bob’s
depression and his ethical convictions. It is also the case that therapists
who create a “safe place” for clients to talk about their psychological
problems also create a safe place to make ethical changes. Finally,
therapists may use strategies tied to particular theoretical approaches to
help clients adopt particular visions of mental health or ideal human
functioning, visions inextricably tied to a set of ethical convictions (this will
be addressed in Chapter 9). In all those cases, the ethical influence is an
unintended therapy outcome.
Therapists also intentionally employ processes that either address or
influence some ethical dimension of a client. These processes may include
persuasion (Beutler 1979), social influence, modeling, collaboration in
determining goals for therapy (Bergin 1991), education (e.g. about the
consequences of various ethical alternatives), pointing out contradictions
in an ethical position (Meehl 1981), and converting clients to the ethical
stance of therapists (Bandura 1969; Corey et al. 1993; Meehl 1959; Strong
1978; Tjeltveit 1986). Distinguishing between processes whose ethical
impact is an unintended side effect and those in which the impact is
intentional is often difficult, however, because the same processes may be
used in both. This may be especially true when moral, religious, and
political values are tied to therapists’ or clients’ ideas about good
psychological functioning. If mental health for Dr Peterson means an
internal psychological source of ethical authority, but for Bob an external
divine source, changes in Bob’s ethical theory may come either as an
unintended side effect or as a (partly unconscious) desire on Dr
Peterson’s part that Bob adopt his ethical theory. Finally, as Frank and
Frank (1991) point out, therapists who deny they are exerting any ethical
influence on clients may, by doing so, actually increase their influence.
168 ETHICS AND VALUES IN PSYCHOTHERAPY
I am aware that lists of possible influence processes are a poor substitute
for a definitive account of the processes that actually influence clients.
Unfortunately, we do not know the exact nature of the processes through
which therapy influences the ethical dimensions of clients’ lives. More
extensive context-sensitive research—quantitative, hermeneutic, or both—
would no doubt help. But the influencing process may vary from therapy
relationship to therapy relationship, and from therapist to therapist. And
so the matter is very complex indeed. Progress will come, I suspect,
through research efforts on the interface between social psychology and
clinical psychology (e.g. Ruble et al. 1992; Snyder and Forsyth 1991, and
that reported in the Journal of Social and Clinical Psychology) and through
scholarly and clinical work drawing upon, and integrating, scientific,
clinical, and ethical resources.
Inappropriate, appropriate, and ideal influence
The processes through which therapists influence the ethical dimensions
of clients’ lives can be ethically evaluated: some processes are
inappropriate (not good, unethical, wrong, blameworthy); others are
appropriate (not wrong) or ideal (good, right, virtuous). In making those
assertions, and in this section, I assume (as argued above) that we should
do so from a position somewhere within the ample middle ground
between relativism and absolutism.
Coercive therapist processes are clearly wrong, save perhaps as a
temporary expedient in psychiatric emergencies or cases of child abuse.
Also inappropriate are processes that violate the therapeutic agreement,
fail to provide clients with adequate information about therapy, and
eliminate or reduce client freedom (Tjeltveit 1986). Therapists
inappropriately reduce freedom by exerting undue pressures on clients to
adopt their moral values, being moralistic or judgmental, or
propagandizing (inaccurately presenting ethical options to clients to
make them more likely to adopt the views of the therapist; e.g. “If you
really want to become healthy, you’ll adopt my views on this
controversial ethical topic”). For those reasons, the conversion of a
client’s values and ethical theory to those of his or her therapist is, prima
facie, unethical. Therapists should not make clients their ethical clones.
However, as we shall see, some forms of therapist influence on the
ethical lives of clients, some forms of ethical conversion, may well be
appropriate, and even ideal.
Other forms of therapist influence on clients can also be inappropriate.
Paternalism, telling clients what to do and taking responsibility for
decisions that are properly theirs, is problematic. Kovacs exemplified this
attitude in his grandiose claim that therapists should “embrace…our
essential role as secular priests” (Kovacs 1987:16). Judging, condemning,
and treating people as objects or mere means to an end are also
inappropriate.
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 169
Other forms of ethical influence are less than ideal because they lead to
negative outcomes. Harmful psychological consequences (increased
symptoms) can result from therapy processes that are judgmental, cause
shame, or undermine trust in therapy (Nicholas 1994). For example,
therapist condemnation, however subtle, of clients who have engaged in
unusual sexual practices, or have never engaged in sexual activity at all,
can harm clients.
Because of the harmful consequences for clients of negative ethical
evaluations, some inexperienced therapists swing to the opposite pole
and attempt to make only positive evaluations. Clients are unlikely to be
convinced by this, however, especially if carried to an extreme. And
providing positive evaluations in all cases is muddleheaded, since
therapists would need to praise diametrically opposed actions or
thoughts. Sometimes helpful with overcontrolled, hyper-responsible
clients, consistently positive feedback is not helpful with
undercontrolled, irresponsible clients. And providing it may stunt a
client’s ethical growth.
Finally, interventions may be inappropriate because they produce
negative ethical consequences, as defined by clients or others. If therapist
influence reinforces sex role stereotypes, for instance, that intervention is,
by feminist ethical standards, inappropriate. The therapeutic ploy of
eliminating all client ethical convictions (all “shoulds”) may also be
deleterious. And Doherty strongly rejects therapeutic interventions that
reduce political activism. He laments that:
although therapists do not tell clients to be politically passive, I see
many therapists negatively interpreting their clients’ public-service
sensibilities and activities. One of Anna’s therapists suggested that
she was not so much serving other families through her teaching as
trying vicariously to heal her own family.
(Doherty 1995: 98)
Therapist interventions may also harm the family and friends of clients, or
society as a whole. If Dr Peterson succeeds in convincing Bob to reject his
responsibilities as father, for example, his children will be harmed. If Dr
Peterson and other therapists consistently defraud third-party payers,
society will be harmed. From the perspective of those who think it is not
good to harm others, those forms of therapy influence, of therapy process,
are—if unaccompanied by countervailing benefits—inappropriate.
By way of contrast, interventions that we evaluate positively will either
meet the minimal standards of professional ethics (and so be considered
appropriate) or meet aspirational standards (and so be considered ideal).
Discussing appropriate or ideal therapist influences on the ethical
dimensions of clients’ lives is the topic to which I now turn.
Some dimensions of appropriate ethical influence have been discussed
previously. Therapists should honor and uphold the therapeutic
170 ETHICS AND VALUES IN PSYCHOTHERAPY
agreement, fully informing clients about relevant ethical dimensions of
therapy and obtaining their full and free consent to therapy. Therapists
should preserve and enhance client freedom, eschewing paternalism and
enabling them to make decisions that are properly theirs. And clients
should be treated with respect, as persons of intrinsic worth.
To evaluate therapists’ influence on the ethical dimensions of clients’
lives, many therapists use a traditional standard: “Psychotherapists
should be neutral.” Because “neutrality” bears so many connotations and
because I think therapists should aspire to some forms of “neutrality,” but
not others, I want to unpack some of the meanings of “neutrality,”
discussing it in some detail.
Critics of therapeutic neutrality sometimes characterize “neutrality” in
an oversimplified way: “Therapists should hold no views on ethical
topics. But if they do, they should never in any way communicate their
views to clients.” That “neutrality” is scarcely a realistic ideal. But
advocates of therapist neutrality hold a variety of more sophisticated, and
defensible, understandings of neutrality. Franklin (1990), for instance,
distinguishes between five separate meanings of neutrality within the
psychoanalytic tradition: behavioral, attitudinal, interpersonal,
interactional, and essential. To sort out the meanings of “neutrality” and
to understand better appropriate and ideal therapist “neutrality,” I will
consider his taxonomy in greater depth.
Therapists who aspire to the ideal of behavioral neutrality strive to be
ethically anonymous with their clients (Franklin 1990). When therapists
do not communicate their ethical views to clients (are ethically
anonymous), clients can feel more free to express themselves, need not
fear being judged, are less likely to feel pressured to adopt or espouse their
therapists’ ethical views, and can more easily take full responsibility for
developing more mature ethical views, views they have chosen. And
therapist and client can focus on therapeutic goals rather than on ethical
issues that may be tangential, or irrelevant, to those goals. For those
reasons, although complete anonymity is impossible (even Carl Rogers
conveyed his ethical views to clients—Truax 1966), “neutrality”
understood in that way has some merit, as a general rule of thumb. It is a
valid aspirational ideal, a way to overcome some of the problems
associated with inappropriate therapist conversion of clients’ ethical
positions.
But to assert that therapists should sometimes strive for ethical
anonymity does not mean they should always do so.
Therapists exhibiting attitudinal neutrality refrain from judgmentalism
(Franklin 1990). Judgmentalism is, of course, an attitude without
advocate. No therapist would defend Dr Peterson if he condemned Bob
because of his moral views. But rejecting judgmentalism does not require
a therapist to be an ethically blank slate. One can hold ethical views (i.e.
make ethical judgments) yet not be judgmental. Forcing a choice between
attitudinal neutrality and judgmentalism is unfair; better alternatives exist.
Advocates of this form of neutrality do, I think, make a legitimate point,
however. But it is not that we should be neutral (in the sense of holding
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 171
or communicating no ethical views); rather, it is that we should be
nonjudgmental. To point out a problematic form of therapist influence
helps little, however, when we need to determine how therapists
appropriately influence clients concerning the ethical dimensions of their
lives.
Franklin argues that therapists exhibiting the third form of neutrality,
interpersonal neutrality, balance their responsiveness to clients. This
“enables the patient to explore both old and new ways of relating to
others” (Franklin 1990:196). Interactional neutrality refers to therapists
interacting with clients flexibly and with open-mindedness. Franklin thus
affirms “balance,” “client exploration,” “flexibility,” and “openmindedness.” All are ethical ideals regarding therapy process. The claim
that therapists are neutral thus actually means that therapists adhere to
particular ethical ideals for therapy process, rather than being entirely
neutral ethically. If therapists are not neutral in the therapy processes
they pursue, they may still be neutral about client goals. As we shall see,
however, Franklin is hardly neutral about therapy’s goal.
Finally, Franklin argues for essential neutrality, by which he means
tolerance of ambiguity, “an absence of decided views,” “a searching
process,” and thinking in terms of “provisional hypotheses rather than
certainties” (Franklin 1990:197). The ultimate value of essential neutrality
is “furthering the open-ended process of self-inquiry,” therapy’s goal and
Franklin’s summum bonum.
Franklin’s claim that neutrality means an “absence” of views lends
support to the claim of R.May (1953) and Christopher (1996) that
“neutrality” represents a particular, profoundly problematic ethical viewpoint: relativism. Although that is a plausible interpretation of the views
of Franklin and other advocates of neutrality, other interpretations are
possible. And, in the case of Franklin, more more apt. Franklin does not
argue that therapists should have no views, but that they should have no
“decided” views. That is, therapists should not hold views so firmly they
cannot be reconsidered, or decided in a new way. His ideal therapist
operates on the basis of several strongly held ethical ideals or virtues:
tolerance of ambiguity, flexibility, tentativeness, and open-endedness.
Franklin argues that those therapist virtues will benefit clients who
seek a process of self-inquiry. And they do seem well suited to help
overcontrolled, very responsible clients from intact ethical communities
(Wallace 1991). But I do not think that those therapist virtues will be most
helpful to the undercontrolled, irresponsible client who has no operative
ethical community, the client who wants only symptom relief or only to
satisfy the authority figure who ordered treatment. For the latter kind of
client, “flexibility and open-endedness” regarding ethical convictions are
not ideal therapist virtues. They will not permit an optimal therapist
response to client ethical convictions like, “I should be able to come to
therapy drunk,” or “A man should be able to have sex with his woman
whenever he wants to. That’s not rape.” Structure, limits, and
consequences are needed in such cases, not “neutrality.”
172 ETHICS AND VALUES IN PSYCHOTHERAPY
I don’t think neutrality in and of itself implies relativism for another
reason: therapists with full sets of ethical convictions can try to minimize
their ethical influence on clients (be “neutral”) because they are
convinced that doing so is in the best interests of clients. On the other
hand, ethical relativists can try to impose relativism on their clients (and
so be anything but neutral). The full spectrum of types of influence,
ranging from value-freedom or neutrality to imposing one’s will on
clients, can be exerted on the full range of ethical positions, ranging from
relativism to absolutism.
Thinking about ethical influence on therapy clients in terms of a
spectrum of influence, ranging from no influence to extensive influence,
is, I think, more helpful than using a dichotomous “neutral” or “not
neutral” (see Doherty 1995). The task therapists face is best understood as
determining, not whether to be neutral, but how much influence, and what
kind, to exert on a particular client at a particular time. That will depend
on client needs and goals, and requires judgment.
I am also convinced we need to use new terms to discuss the legitimate
ethical concerns historically expressed by “neutrality.” An alternative:
therapists should, as a general rule and unless there are compelling
reasons to do otherwise, strive to minimize their ethical influence on
clients. Aponte espoused such a view: therapists should “attempt to
exercise no more influence over clients’ values than is required to address
clients’ problems” (Aponte 1994:184). This language transcends the false
dichotomy of value-freedom or neutrality on the one hand, and imposing
one’s ethical views on clients, on the other. Yet the essential insight of the
traditional view is maintained: clients’ best interests are often not served
when therapists voice their ethical convictions or otherwise attempt to
influence the ethical dimensions of clients’ lives. This is, in fact, an old
view. Hartmann asserted that the analyst’s personal moral valuations are
“best kept in the background” (Hartmann 1960:55, emphasis added). His
discouraging therapists from expressing their views was a general
guideline, not an absolute prohibition. In his view, and mine, therapists
properly emphasize what “is required to address clients’ problems.” And
that may or may not require addressing or attempting to influence the
ethical dimensions of clients’ lives.
Another way in which therapists appropriately address ethical issues is
to refrain from making ethical judgments in the early stages of a
therapeutic relationship. This captures a valid insight in the idea that
therapists should be neutral: not making ethical judgments can be a
vitally important but temporary expedient early in therapy. More
explicitly, ethical discourse generally occurs, if at all, in the later stages of
therapy. And so therapists do not stop making ethical judgments, but do
suspend them temporarily.
Therapists are advised to avoid making ethical judgments early in
therapy so they can provide the conditions necessary for resolving the
problems bringing a person to therapy, to produce an ethical moratorium
that benefits clients. As espoused by Erikson (1963), a moratorium is a
stage between the immature moral views of childhood and the ethical
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 173
maturity of an adult. To reach ethical maturity, one must pass through
that stage. Likewise, therapists may refrain from expressing their ethical
views to enable clients to examine their childhood ethical convictions and
move to those of adulthood. As Wallace pointed out, dynamic
psychiatry’s “temporary suspension of standard moral evaluative
categories is a means to self-insight, to self-transformative ends” (Wallace
1991:112). Humanistic psychologies, claims Browning, “may be
particularly powerful in providing the psychological space necessary for
the arousal of deeper capacities for freedom, initiative, and agency”
(Browning 1987:92).
But not making ethical judgments is temporary and should not be seen
as “a recipe for amoral living” (Wallace 1991:112–13). As Browning notes
“the temporary and heuristic suspension of moral judgments should not
be confused with the wider elimination of any moral context whatsoever
from our acts of care and counseling” (Browning 1982:11). The nature of
that broader ethical context is, of course, disputed.
Clinical judgment is required to decide the appropriateness of overtly
addressing ethical issues. As Doherty points out, timing is critical:
“Listening, reflecting, and affirming must precede any ethical challenge
in psychotherapy; clients must know that we have heard them and care
about them” (Doherty 1995:64). Furthermore, a well-functioning
therapeutic relationship must exist. In the early stages of therapy, he
argues, some “concealment” of the therapist’s views is often
therapeutically important. In successful therapy, however, he “almost
invariably” engages eventually in “full disclosure” (ibid.: 86).
To summarize, “neutrality” has a wide range of meanings.
“Neutrality” cannot legitimately mean, it seems to me, that therapists
never hold ethical views, never communicate them to clients in any way,
are entirely anonymous ethically, or espouse ethical relativism. But
“neutrality” can legitimately mean that therapists should, as a general
rule, minimize their ethical influence on clients (especially in the early
stages of therapy and when doing so would not harm clients), provide a
nonjudgmental environment in which clients feel free to express and
explore ethical issues, exhibit flexibility and open-mindedness, tolerate
ambiguity, be willing to change their ethical convictions, match their
ethical influence strategies (employing the full spectrum of available
options) to client needs and goals, and focus on therapeutic goals. Clarity
would be served, however, by abandoning “neutrality” in favor of
precisely those ethical terms.
Two other alternatives for addressing the ethical dimensions of clients’
lives exist: therapists consciously address ethical dimensions of clients’
lives, or therapists consciously attempt to influence them. Although
addressing ethical issues may have the effect of influencing them,
therapists who simply address the ethical dimension of clients’ lives
generally attempt to minimize their influence on them and work within
the client’s ethical framework (Aponte 1994). Furthermore, therapists
who consciously try to change clients’ ethical convictions need to provide
greater justification than do those who simply address those convictions.
174 ETHICS AND VALUES IN PSYCHOTHERAPY
And so, while recognizing they are on a continuum and not mutually
exclusive, I distinguish between “addressing” and “influencing.”
Therapists can address ethical issues in a variety of ways, functioning
in the roles of consultant, teacher, and midwife. Meehl (1981) argues that
therapists can “correct” clients’ ethical views without taking a stance on
the content of those views, doing so, for example, by pointing out
contradictions within those views. Glasser asserted that Reality
Therapists are “not afraid to pose the question, ‘Are you doing right or
wrong?’” (Glasser 1965:58). They confront clients with disparities
between their beliefs and behavior.
Discussing the consequences of ethical alternatives is another way
therapists can help clients to make ethical decisions (Corey et al. 1990;
Schimmel 1992), one that relies upon a teleological ethical theory and
draws upon science. Dr Peterson could thus respond to Bob’s question,
“Does it really hurt kids when their parents get a divorce?” with relevant
scientific findings conveyed in a manner suitably tailored to his needs at
that point in therapy. In that and other ways, therapists can help clients to
clarify their ethical convictions. Values clarification can be understood in
a variety of ways, however. It has been criticized for promising the
chimerical but “alluring possibility of moral neutrality” (Meilaender 1984:
79). Although some therapists may think values clarification is morally
neutral, others try to clarify values because they are convinced that some
clients improve when not confused about values. A belief in the benefit to
clients of ethical clarity, one of a therapist’s many ethical convictions,
may thus motivate therapeutic efforts to clarify clients’ values rather than
a myth about value clarification’s ethical neutrality.
Therapists and clients can also talk about ethical issues (Feminist
Therapy Institute 1990; Odell and Stewart 1993), doing so in a way that
preserves client freedom and is not intended to change clients’ ethical
views. Dr Peterson could simply ask Bob about his ethical convictions
concerning marriage and forgiveness, and engage him in a conversation
about them. When viewed from a hermeneutic point of view, discussions
about ethical issues offer “the possibility of a more probing and
ultimately challenging dialogue that more directly confronts traditional
issues of values” (L.A.Sass 1988:255).
Acknowledging and affirming clients’ ethical assumptions, Doherty
(1995) argues, is another way therapists address ethical issues. He does
so, for instance, by including questions about clients’ community service
activities on his intake form. And in the late stages of therapy, he asks
clients how they will use what they have learned in therapy on their jobs
or in their communities. Doherty set forth a taxonomy of responses
therapists can make to clients about ethical issues, from least intense to
most intense. Because the most intense involve therapists consciously
trying to influence clients, I list here only the five that are least intense,
that involve therapists addressing ethical issues. Therapists, Doherty (1995:
42–4) asserts, can:
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 175
1 Validate the language of moral concern when clients use it
spontaneously.
2 Introduce language to make more explicit the moral horizon of the
client’s concern.
3 Ask questions about clients’ perceptions of the consequences of their
actions on others, and explore the personal, familial, and cultural
sources of these moral sensibilities.
4 Articulate the moral dilemma without giving the therapist’s own
position.
5 Bring research findings and clinical insight to bear on the
consequences of certain actions, particularly for vulnerable
individuals.
Clinical judgment is required to determine whether, and when, to use
each. For example, in a first session with Bob, a therapist would be wise
to go no further than the first level.
Therapists who address ethical issues in therapy function as moral
consultants, Doherty maintains. Drawing upon Wolfe (1989:11), he
argues that:
the therapist’s role is to try “to locate a sense of moral obligation in
common sense, ordinary emotions, and everyday life…to help
individuals discover and apply for themselves the moral rules they
already, as social beings, possess.”
(Doherty 1995:19)
Addressing the ethical dimensions of clients’ lives without influencing
them is very difficult. For instance, Doherty’s claim that everyone has a
reliable moral sense appears to grow out of his intuitionist ethical theory,
a theory not espoused by everyone. Those employing other ethical
theories might think Doherty was trying to influence clients to adopt his
ethical theory. Similarly, suppose Dr Peterson tries to address ethical
issues in Bob’s therapy by clarifying his client’s values. Bob says, “I really
believe marriage is a permanent commitment. But I really need to begin
looking out for myself. And this time she’s gone too far.” If Dr Peterson
emphasizes either the pro-commitment side of Bob’s ambivalence or the
pro-self-interest side, he will likely not only address Bob’s ethical muddle,
but also influence it.
Consciously addressing ethical issues may thus sometimes influence
clients. But the reverse can also occur: consciously attempting to
influence clients’ ethical convictions may not work; clients might not
change their views. Conscious attempts to influence clients can thus
become ways in which therapists address ethical issues.
176 ETHICS AND VALUES IN PSYCHOTHERAPY
Controversy arises, however, when therapists consciously influence the
ethical dimensions of clients’ lives rather than simply addressing them
(Doherty 1995). But advocacy of ethical influence on clients is not new,
albeit a muted theme in the history of therapy. Despite the emphasis of
his psychoanalytic descendants on neutrality, and the assertions he made
that support that emphasis on therapeutic neutrality, Freud argued that
“we are often obliged, for therapeutic purposes, to oppose the superego,
and we endeavor to lower its demands” (Freud 1961:143). Although he
distinguished between the superego and genuine ethical convictions,
Freud no doubt influenced the latter in his conscious efforts to influence
the former (and that very distinction can only be made on the basis of
some disputed ethical view). Dreikurs was more explicit: “Changing the
value system on which patients operate, constitutes an essential part of
psychotherapy” (Dreikurs 1967:103).
The trend to advocate explicit therapist ethical influence on clients is a
profoundly important development in a profession historically
characterized by devotion to value-freedom and ethical neutrality and by
a general neglect of therapy’s ethical character. And such explicit ethical
influence on clients is likely to increase as the number of managed care
therapists, trained to be “directive” (Austad and Berman 1991b: 265),
increases.
Although I welcome this trend for several reasons, I welcome it
cautiously, embracing it only if therapists exercise influence responsibly
and well, giving due attention to protecting client rights and autonomy,
insuring that clients are not harmed, and otherwise pursuing such
influence appropriately, as discussed in this chapter.
Unfortunately, the range of efforts to influence clients that is
considered appropriate is wide. At one extreme is Kovacs’ (1987)
sublimely confident role as self-appointed priest, and a therapy
supervisor quoted by Nicholas. She consulted him about a client who
was selling marijuana. His unequivocal response:” ‘Simple,’ said Bob.
Tell him it’s unethical, and that he can’t get better if he does it. Unethical
behavior and mental health are contradictory’ ” (Nicholas 1994:v).
Other therapists exert ethical influence in a more nuanced (and
responsible) manner, exhibiting greater awareness of potential problems,
showing sensitivity to clients’ psychological status, tailoring their
influence strategies accordingly, and generally exhibiting wisdom as they
address the ethical character of therapy (Cushman 1995; Doherty 1995).
Doherty’s (1995) repertoire of influence strategies includes a spectrum
of approaches, each respecting client autonomy and matched to the needs
of the client and the current state of the therapeutic relationship. He
raises ethical issues with clients in the early stages of therapy when
appropriate and in ways (discussed above) that make ethical discourse a
natural part of the therapeutic relationship. He engages in more active
forms of ethical influence only when a well-functioning therapeutic
relationship has developed. Even then, “caring and timing” are
paramount. He explains that:
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 177
listening, reflecting, and affirming must precede any ethical
challenge in psychotherapy; clients must know that we have heard
them and care about them. Furthermore, the client must have
responded positively to some other clinical challenge in the
nonmoral domain, such as a challenge to examine distorted beliefs
or unacknowledged feelings, or to try out a new, probably
uncomfortable behavior.
(Doherty 1995:64)
Only then will Doherty make one of his more intense responses to
clients:
6 Describe how you generally see the issue and how you tend to
weight the moral options, emphasizing that every situation is unique
and that the client will, of course, make his or her own decision.
7 Say directly how concerned you are about the moral consequences of
the client’s actions.
8 Clearly state when you cannot support a client’s decision or
behavior, explaining your decision on moral grounds and, if
necessary, withdrawing from the case.
(Doherty 1995:44–5)
Preserving the autonomy of the client is vital when therapists consciously
attempt to influence the ethical dimensions of clients’ lives. Hoffman
(1979) emphasized the need for therapists to assure clients that
disagreement with their therapist is okay. And that clients have a right to
disagree with their therapists. Therapists need to provide such assurance
whenever they ethically confront clients. Doherty argues that therapists
need to monitor their reactions when clients disagree with their ethical
stance. In contrast to moralistic therapists, the morally sensitive therapist
“will explore the areas of diverging opinions and then back off’ (Doherty
1995:65). And he offered a helpful guideline: “If a client always ends up
agreeing with the therapist, the therapist is probably doing something
wrong—being coercive, shaming, or unaware of the client’s need to
please” (ibid.: 84).
Some therapists argue that therapists should limit their ethical
influence on clients to issues directly related to therapy goals. Others,
including Cushman (1995) and Doherty (1995), argue that a more general
kind of ethical influence on clients is also legitimate. This valid general
ethical influence pertains to universally applicable ethical ideals, to the
interests of others as well as the client, and to long-term and not simply
short-term consequences of clients’ actions. I want to address those two
general views.
178 ETHICS AND VALUES IN PSYCHOTHERAPY
Some argue that the ethical influence therapists exert should be
limited, to mental health values, to ethical convictions directly tied to
therapy’s psychological goals. Although not in the most recent version,
the 1973 ethics code of the American Psychiatric Association codified that
view: “The psychiatrist…should not use the unique position of power
afforded him by the psychotherapeutic situation to influence the patient
in any ways not directly relevant to the treatment goals.” Therapist
influence should thus be restricted to those problems for which therapists
are competent (trained) to treat (i.e. psychological but not ethical
problems), and should be consistent with the agreement between
therapist and client, which is generally about psychological problems,
not broader ethical issues (Tjeltveit 1986). This position requires a sharp
distinction between psychological problems and well-being, on the one
hand, and ethical issues, on the other. But that distinction, for reasons
outlined in the discussion of therapy goals in Chapter 9, is difficult to
make.
By way of contrast, Doherty explicitly attempts to promote a more
general “ethical self-empowerment,” doing so in the careful way
described above. Indeed, he even asserts that therapists “have a
responsibility to help our clients avoid compromising themselves
ethically” (Doherty 1995:54). He distinguishes between “personal
values,” like the value of a good education, which are private and
idiosyncratic, and “moral convictions,” like commitment, “the moral
linchpin of family relationships” (ibid.: 24–5). Although he may attempt
to influence clients regarding the latter, he will not attempt to influence
the former. He also encourages clients to consider the well-being of their
family and community as well as their own well-being, an ethical theme
Cushman (1995) addresses as well.
Both limited and general ethical influence are often justified in terms of
positive outcome: clients will be better off psychologically, ethically, or
both. Clients and their families, friends, and communities will benefit.
And client moral integrity will be preserved or enhanced (Buhler 1962;
Doherty 1995). But to justify process in terms of outcome, we need to
address the ethical status of that outcome, a task I will address in
Chapter 9.
Unfortunately, one person may think a therapy process ethically
appropriate, but a second person may think it inappropriate—because
the ethical convictions upon which each bases his or her judgment differs
from that of the other. A problem with Doherty’s laudable approach is
that he appears to be slow at times to recognize that other people
sometimes disagree with his ethical views (like his controversial
assumptions that everyone has a sense of moral obligation and that
moral convictions are clearly distinguishable from personal values). If he
empowers clients ethically, with which ethical convictions does he
empower them?
Other therapists exhibit that tendency to a greater extent. The
American Psychiatric Association Committee on Religion and Psychiatry
(1990) criticized a therapist who regarded his client’s homosexual
ETHICAL DIMENSIONS OF THE TECHNIQUES, STRATEGIES, AND PROCESSES 179
orientation to be sinful. That therapist may have tried to ethically
influence his client in accord with his own “moral convictions.” And
Wendorf and Wendorf (1985) criticized Margolin (1982) for imposing her
feminist values on clients. Nicholas (1994) approvingly reports a
therapist’s success in changing a client’s definition of what is moral,
changing it to her own idiosyncratic ethical views.
And so differing evaluations of the appropriateness of ethical influence
on clients often hinge on ethical differences among the evaluators. Some
ethical differences are at the level of specific values (defined ethically), but
others are at the level of ethical theory. At both levels, most
contemporary societies are sometimes deeply divided. Because those
profound ethical divisions affect therapy and judgments about it, they
represent a deep and challenging problem that therapists and other
therapy stakeholders need to address. And to which I will return in
Chapter 10.
I now want to turn to the sixth and seventh ethically relevant
dimensions of therapist process.
Helping clients
Some argue that appropriate or ideal therapy processes are those that
help clients. That leaves unanswered two important questions: what does
it mean to help clients? and, what do therapists do when helping a client
conflicts with some other ideal for therapists? For instance, a therapist
may be able to remove a client’s presenting problem (help the client) but
only by paternalistically reducing his or her autonomy.
The ideal solution to such ethical dilemmas, of course, is to help clients
in a way that benefits them, preserves their rights, and otherwise meets
the ethical ideals discussed in this chapter. When such perfection cannot
be achieved, clients, therapists, and other stakeholders must exercise
prudence when dilemmas arise, determining the best possible balance of
those ideals, a balance that is rarely perfect.
Some argue that research will tell us how to help clients. When
answers are obtained (and some have been obtained) therapists should
then employ methods empirically proven to be effective. As I have
argued previously, there is substantial merit in properly qualified forms
of this ethical position. But it leaves unanswered the question I will
address in Chapter 9: which therapy outcomes, which therapy goals, are
good, right, and/or virtuous?
Choice of therapy goal(s)
One more issue of process needs to be addressed: by what process should
therapy goals be determined?
Szasz (1965) asserted that Freud’s greatest contribution was creating a
new role for the psychiatrist: agent of the client rather than agent of
180 ETHICS AND VALUES IN PSYCHOTHERAPY
society. Accordingly, clients should choose therapy goals, and therapists
are obligated to respect those choices. Rogers strongly encouraged
therapists to give “full freedom” to clients, including the freedom to choose
any goals, whether “social or antisocial, moral or immoral” (Rogers 1951:
48).
Several difficulties face the idea that clients alone should select therapy
goals. As Lowe (1976) notes, some clients are too confused to state their
goals. Furthermore, in the current climate, unless clients are sufficiently
rich to pay for therapy on their own, third-party payers expect to play a
role in determining the goals of a particular therapeutic relationship. And
Austad and Berman note that therapists employing brief therapy
techniques are required to “take responsibility for the content and
direction of therapy” (Austad and Berman 1991b:265, emphasis added).
Therapists may think some client goals inadvisable. For example, most
therapists would think it a mistake for Dr Peterson to accede to Bob’s
request to tell him whether to forgive his wife and stay in his marriage.
That would not be in Bob’s best interests. Permitting Bob to choose his
own therapy goals and helping him would thus be in conflict.
Drawing upon the ethical principles discussed in this chapter sheds
light on this problem, however. Dr Peterson should try to maximize
Bob’s autonomy, treat him with respect, balance his autonomy with Dr
Peterson’s own ideas about what would be most helpful to Bob, and
influence Bob appropriately. A dialogue (Berger 1982; Bergin 1991)
between Bob and Dr Peterson, and, as applicable, among Bob, Dr
Peterson, and Bob’s third-party payer, should develop a clear consensus
about therapy goals and expectations. That may also contribute to a
successful outcome (Orlinsky et al. 1994).
Convictions about therapy goals are again relevant, as therapy
stakeholders need to evaluate whether proposed therapy goals are
realistic and appropriate (Carroll et al. 1985). Or, better yet, ideal. And so
the process of negotiating therapy goals hinges in part upon an ethical
evaluation of alternative goals, which I will address in Chapter 9.
Having established in exhausting detail that therapy processes can be,
and need to be, ethically evaluated, I now turn to the intimately related
topic of ethical evaluations of therapy goals and outcome.
9
Ethical dimensions of the goals and
outcome of therapy
Therapy as means to which (ethics-laden) ends?
Psychotherapy goals have an ethical character, a disputed ethical
character. Those goals, and therapy outcomes, can be evaluated ethically
by therapy stakeholders, who should develop and articulate more
sophisticated and ethically adequate convictions to guide and assess
therapy.
To ground this discussion of those controversial assertions, I want to
revisit the clinical example used in Chapter 8, examining the goals of
three of the stakeholders in Bob’s therapy: Bob wants to be less confused,
Dr Peterson wants Bob to develop greater insight into the unconscious
and childhood roots of his current difficulties, and Bob’s third-party
payer wants a cost-effective reduction of his psychiatric symptoms. We
can ethically evaluate those goals because each stakeholder thinks it
would be good if, by the end of Bob’s therapy, that stakeholder’s goal is
reached. We can also ask which therapy goal (if any) is ethically superior
or best.
Therapy outcomes also have an ethical character. Suppose Bob’s
therapy has the following outcome: he is less depressed and no longer
confused, having decided to divorce his wife. He made that decision after
taking seriously his therapist’s encouragement to “Take better care of
yourself.” Dr Peterson employed that intervention to “lower the
demands” of Bob’s “overactive” superego, to free him so he could
develop some insight. As part of “taking better care” of himself, Bob,
primary caretaker for all three children during the year-long marital
separation, had mounted an aggressive effort to insure that his soon-to-be
ex-wife accepted “fair” (50/50) responsibility for taking care of the threeyear-old daughter they had together and complete custody of her nineyear-old son (whom Bob had adopted), the product of her first marriage.
Therapy did not last long, and so was not expensive, but Bob gained little
insight into the deeper roots of his problems. The previously welladjusted children had, however, developed problems. Two of the three,
and especially the son, were acting out and seriously depressed.
The goals set by Bob and his third-party payer were thus reached, but
not the goals of Dr Peterson. Furthermore, one outcome, therapy’s
harmful impact on Bob’s children, was a goal set by no one.
182 ETHICS AND VALUES IN PSYCHOTHERAPY
If we ethically evaluate the outcome of Bob’s therapy, we might
conclude that Bob’s decreased confusion and depression and therapy’s
low cost were good outcomes, but Bob’s lack of insight was not a good
outcome. And the harm to the children was a bad (harmful, negative)
outcome. We can also ask whether a better outcome might have
occurred, an outcome preserving Bob’s gains (and possibly holding
therapy costs low) while reducing the harm to his children (and possibly
increasing his insight). I relegated the outcomes of low cost and increased
insight to parentheses in that last sentence because, in my ethical
judgment, they are less important: Bob’s well-being and that of his
children are more important criteria (principles, ideals, ethical standards)
by which to judge the outcome of his therapy. A psychoanalyst or
managed care company executive might disagree with my ranking,
however. Ethical evaluations of therapy goals and outcomes are disputed.
Some argue that establishing goals and evaluating therapeutic
effectiveness are purely technical or scientific matters, and not ethical. I
acknowledge the technical and scientific dimensions of those tasks, but
argue in this chapter that those tasks also have ethical dimensions. Any
judgment of therapy’s “effectiveness,” for instance, hinges upon some
ethical criterion by which effectiveness is judged, upon evaluative
(ethical) as well as descriptive considerations. As Orlinsky and Howard
point out:
the judgment of psychotherapeutic outcome is a complex procedure
involving two distinct steps often compounded in practice. The
description of the changes that are probably consequences of
participation in psychotherapy is only the first step. Logically, the
second step is an evaluation of these changes with reference to explicit
value standards.
(Orlinsky and Howard 1978:320–1)
Addressing the ethical character of goals and outcome, how goals and
outcome pertain to what is good, right, and/or virtuous, can mean
ethically critiquing the goals and outcome of a particular therapeutic
relationship (as I did in a very limited fashion with Bob’s therapy) or of
some general approach to therapy (e.g. Rogerian). Addressing goals and
outcome evaluatively can also mean formulating ideals, or optimal ethical
standards or criteria, to be used to establish the best possible therapy
goals and the best possible ethical assessment of outcome. Clarifying
optimal ethical standards for therapy goals is especially important (if
controversial) because—if some therapy goals are better (more good)
than others and we know which are best—therapists should pursue those
better goals (W.F.May 1984).
Goals and outcome are closely related, although distinguishable. A goal
is what one or more stakeholders want or intend to happen in therapy;
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 183
outcomes are what actually happens, which may or may not correspond
to stakeholders’ goals.
In attempting to understand the ethical character of therapy goals and
outcome, I adopt a broad approach. I will consider the ethical dimensions
of goals and outcomes found in various schools of therapy. But I will not
limit the discussion to theories and theoretically-derived concepts
because I also want to address dimensions of therapy—seen in particular
therapeutic relationships and in therapy in general—not necessarily well
captured by advocates of particular positions. For example, those
advocates often emphasize, not how their approaches are like those of
others, but how they are unlike.
I am also convinced that such ethical evaluations appropriately include
careful analyses of therapy narratives. The stories told by therapists,
clients, and other therapy stakeholders often pertain to what they perceive
to be its good, right, and/or virtuous ends. As Guignon points out, the
narratives constructed by therapy participants “have a ‘moral’ to the
extent that their resolution implies the achievement of some goods taken
as normative” (Guignon 1993:236).
Finally, as discussed in the previous chapter, I do not sharply divide
process and outcome. And so, for two reasons, I will include in this
chapter what some call process. First, what one person calls therapy
process (e.g. insight), a means to therapy’s proper goals, another might
call a positive outcome. Second, for some theorists, process and outcome
are indistinguishable. Dewey, for instance, asserted that “growth itself is
the only moral ‘end’ ” (Dewey 1920:177). Dewey-inspired therapists thus
argue that the goal of good therapy (growth) is indistinguishable from its
process (growth). (Not surprisingly, relationships between advocates of
this viewpoint and managed care representatives are often rocky.)
Unfortunately, many therapists strenuously resist precisely the kind of
ethical reflection on therapy goals and outcome for which I am arguing.
This is true, even of therapists otherwise willing to engage in ethical
reflection about therapy, true for several reasons discussed earlier. I will
mention three.
Many therapists are taught not to make ethical evaluations about the
ends of therapy, to judge which ends are worth pursuing (Guignon 1993;
Richardson and Woolfolk 1994). Indeed, many are “loath” to do so
(Parloff 1967:8), perhaps because they believe such evaluations are
beyond their competence or are impossible to do rationally (MacIntyre
1984).
In addition, some ethical assumptions to which therapy goals and
outcome are tied are so widely held that their ethical character goes
unrecognized. For example, Leahey notes that some US psychologists do
not notice the ethical character of “individual growth” because it is “so
American as to be transparent” (Leahey 1992:371; see Taylor 1989).
Because of a widespread ethical consensus at some levels of abstraction,
therapists often easily negotiate therapy goals and evaluate outcome. But
ethical issues are still present in consensual goals, and deep differences
among therapy stakeholders often underlie apparent consensus.
184 ETHICS AND VALUES IN PSYCHOTHERAPY
Furthermore, therapists can easily formulate goals in ways that command
assent among clients but actually mask underlying differences. For
example, suppose that when discussing goals with Bob, Dr Peterson had
said, “Okay, then, so what we need to do in therapy is get a handle on
this stuff you’re wrestling with and get you feeling better.” Hearing that,
Bob may assume he and Dr Peterson shared goals, whereas in fact Dr
Peterson’s unvoiced goal was to increase Bob’s insight, rather than
“merely” reducing his confusion and relieving his symptoms. And so
superficial agreement about therapy goals may retard deeper ethical
reflection about goals and outcome.
Finally, many therapists resist ethical reflection on therapy goals and
outcome because they employ an unduly restricted conception of ethics
(MacIntyre 1984; Taylor 1989), a conception focused, in Taylor’s words,
on “what it is right to do rather than on what it is good to be” and on
“obligation rather than the nature of the good life” (Taylor 1989:3). And
MacIntyre points to the frequent neglect of virtue and character in
discussions of ethics. But questions of goodness and virtue are often more
relevant to therapy than questions about right and wrong. We need to ask
those broader ethical questions, excluded from narrow conceptions of
ethics, to address well the ethical character of therapy goals and
outcome.
Despite therapy stakeholders’ overdetermined resistance to reflect
ethically on therapy goals and outcome, it is, I think, vitally important to
do so. Indeed, I think it so important I will repeat from previous chapters
several overlapping reasons for therapy stakeholders to do so: to
understand therapy’s ethical character (“a theory of scientific progress
needs an axiology of inquiry, whose function is to certify or de-certify
certain proposed aims as legitimate”—Laudan 1987:29), to uncover and
address ethical differences underlying superficial similarities, to become
more explicit about implicit ethical assumptions, to help us better
evaluate goals and outcome, and to facilitate discourse among all of
therapy’s stakeholders about appropriate (and ideal) therapy goals and
about public philosophies and public policies concerning the optimal role
of therapy in a given society (to be discussed in Chapter 10). At its most
fundamental level, however, we need to discuss therapy goals and
outcome because therapy is supposed to help people (beneficence is
central to the psychotherapy professions). But we need to be clear about
what it means to help people. And that requires ethical analysis of therapy
goals and outcome, because helping people means helping them change
in some positive direction, which direction can be evaluated ethically.
Finally, articulating the ethical sources of therapy’s goals can enhance
therapy’s effectiveness. As Taylor notes, ethical articulacy:
has a moral point, not just in correcting what may be wrong views
but also in making the force of an ideal that people are already
living by more palpable, more vivid for them; and by making it
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 185
more vivid, empowering them to live up to it in a fuller and more
integral fashion.
(Taylor 1992:22)
And so the question should be, not whether, but how to address the
ethical character of therapy goals and outcome. I will first address
problematic approaches, then turn to approaches that are more
promising.
Unsuitable “solutions”
The easiest way to deal with the ethical character of therapy goals and
outcome—and the most irresponsible—is to ignore it. Ethical judgments
about outcome are then tacit, and goals covert. And covert goals, argues
Karasu, are “ethically the most problematic” (Karasu 1980:1505).
As discussed in Chapter 4, some assert that there is always one correct
answer to ethical questions, including the question of the best therapy
goal or outcome. The polar opposite of such absolutism is relativism, the
claim we can make no universally applicable ethical assertions. But as
surely as there is more than one valid goal for therapy, professionals
(understood in a substantive sense) can make at least some ethical
judgments about goals and outcome. We can, for example, rule out
therapy goals like guilt-free pedophilia. And so therapists who endorse
either absolutism or relativism deny their calling as professionals by
fleeing the strenuous complexities of meaningful ethical inquiry.
Extreme skepticism (even if falling short of total relativism) is likewise
inadequate. Drawing upon positivist ethical theory and the emotivist
ethical theory with which it is often associated, many deny that any
ethical assertions can be meaningful. The practical impact of that belief:
asking which end or goal is good or right means nothing more than
asking someone’s preference or emotional reaction. But psychotherapists
cannot, as professionals, fully embrace such skepticism because by the
very nature of being professionals they commit themselves to the well-being
of their clients, to benefit clients, to beneficence. And that requires some
meaningful idea about what it means to help clients, of the good end
toward which clients move in successful therapy. Although some
measure of skepticism about ethical claims is important, and the extent of
justifiable ethical assertions debatable (see below), being a professional
(when the term is used in a substantive sense) requires a commitment to
certain ethical ideals. And so, “a professional who holds no moral views”
is a troubling contradiction.
Also problematic is vulgar pragmatism, my term for the belief that
asking “Does it work?” can tell us which therapy goals to pursue and
how to evaluate outcome. If we claim a therapy goal or outcome should
be adopted (is good) because it works, we need to know for what purpose,
to what end, or for what function it works. That purpose, end, or function is
186 ETHICS AND VALUES IN PSYCHOTHERAPY
assumed to be good; therapy is considered good because it helps us to
accomplish that good purpose, reach that good end, or restore that good
function. But vulgar pragmatism never explicitly specifies those good
purposes, ends, or functions, or gives an account of why they are good.
And unless they engage in those properly ethical tasks, vulgar
pragmatists rely upon covert ethical ideals (unjustified by vulgar
pragmatism) in their ethical evaluations of therapy goals and outcome.
As Richardson and Fowers point out:
it is hard to see how we can evaluate different belief systems or
ways of life…when whatever we mean by pragmatically beneficial
or deleterious will be determined by the standards and values of the
belief system or way of life we currently inhabit!
(Richardson and Fowers 1994:5)
Vulgar pragmatism thus obscures the ethical character of therapy goals
and outcome.
Vulgar pragmatism needs to be distinguished, however, from
philosophical pragmatism, which is one of the approaches that may
prove helpful in exploring the fertile middle ground bounded by the
inadequate alternatives of vulgar pragmatism, absolutism, relativism,
and skepticism. I will turn to that middle ground shortly, but I will first
address one final inadequate approach.
Some argue for a simple answer to the question of psychotherapy’s
goal and optimal outcome: mental health. Partly correct, that simple
assertion is inadequate. It is partly correct because therapists should
emphasize improved psychological functioning as much as possible
(unless having very good reasons not to do so). But it is not the full
solution, for several reasons: there is no consensus about the meaning of
mental health (understood either as freedom from psychological problems
or as ideal psychological functioning) among therapists and among
categories of stakeholders (e.g. between therapists and third-party payers).
All definitions of mental health presuppose more or less controversial
ethical convictions. And the ethical ideals contained in notions of mental
health need to be balanced with other ideals, for example, societal wellbeing.
Fortunately, therapy stakeholders mired in the poverty of ethical
articulation that is reflected in, and exacerbated by, those simplistic
options, can explore a wide variety of more promising alternatives in the
ample middle ground between relativism and absolutism. They can be
skeptical of false ethical claims but still make ethical assertions, can be
pragmatic but articulate the ends toward which such pragmatism aims,
and can strive to help clients reach ideal levels of psychological
functioning with full awareness of the complexities attendant upon doing
so. It is to the ideals employed in those more fruitful approaches that I
now turn.
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 187
Multiple ideals: the diversity of valued therapy goals
and outcomes
We employ a wide variety of ethical ideals—principles, concepts
of goodness, and virtues—to determine therapy goals and evaluate
outcome. “Respect for autonomy,” for example, is a principle used to
claim that therapy should aim at whatever goals clients set for
themselves. Every therapist employs—to some extent—that or other
ideals.
Some regard such ideals as optional, standards to which therapists and
clients may wish to aspire or not. Others assert that some ideals,
especially moral ideals (in contrast to nonmoral ideals), are obligatory.
W.F.May, for instance, argued that with regard to moral ideals “one lives
under the imperative to approximate the ideal; and this task of
approximation is not merely optional” (May 1984:252). Likewise, Taylor
defined a moral ideal as “a picture of what a better or higher mode of life
would be, where ‘better’ and ‘higher’ are defined not in terms of what we
happen to desire or need, but offer a standard of what we ought to
desire” (Taylor 1992:16). Many of the ideals held by clients, therapists,
and other therapy stakeholders are nonmoral ideals, however, not
carrying that obligatory or “ought” quality. In this chapter, I will address
the full range of ideals, moral and nonmoral.
I will begin to address ethical ideals in this section by exploring the
perspectives of different therapy stakeholders. I will then consider various
types of ideals, differing levels of abstraction, the need to tailor goals (to
some extent) to individual clients, contexts, and cultures, and the extent of
the ideals employed. I will also document the diversity of ethical ideals
underlying therapy goals and evaluations of therapy outcome. In the
concluding section, I will discuss how to address these multiple (and at
times contradictory) therapy ideals.
Deciding what is good, right, and/or virtuous in
therapeutic ends: principles, goodness, and virtues
To ethically evaluate therapy goals or outcome, we can employ ethical
principles, some concept of goodness, and/or virtue ethics, the three
approaches to deciding what is good, right, and/or virtuous discussed in
Chapter 4.
We can use ethical principles, like Meara, Schmidt, and Day’s (1996)
respect for autonomy, beneficence, fidelity, justice, nonmaleficence, and
veracity, to select therapy goals and evaluate outcomes. We can do so in
several ways. A principle can serve as a criterion to determine or evaluate
desired ends (the goals or outcome of therapy), can serve as the desired
end itself, or both. For example, the ideal of “respect for autonomy” could
mean that any therapy end that respects client autonomy is ethical, that
the therapy end that most respects client autonomy is ideal or is
obligatory, that any therapy end that fails to respect client autonomy is
188 ETHICS AND VALUES IN PSYCHOTHERAPY
ethically undesirable or wrong, or that successful therapy clients ideally
exhibit respect for autonomy. The first alternative—that “respect for
autonomy” could serve as a criterion to determine or evaluate desired
therapy ends—can also be interpreted in different ways: when Bob wants
his therapist to tell him what to do, for instance, should Dr Peterson
“respect” Bob’s autonomy by accepting Bob’s choice of therapy goal and
tell him what to do? Or would Dr Peterson best respect Bob’s autonomy
by not telling him what to do and engaging him in a course of therapy
that enables Bob to become more autonomous? The first would respect
Bob’s (perhaps autonomous) choice of therapy goal; the second would
respect Bob’s autonomy by helping him develop greater autonomy.
Although ethical principles can be employed as therapy goals, I have
never seen “nonmaleficence,” “beneficence,” or “fidelity” listed as
therapy goals on a treatment plan. “Veracity,” “justice,”1 and “respect for
autonomy” (or synonyms) are occasionally listed, however, especially for
clients who act out. And I have seen goals like “learn to take better care
of oneself,” goals that very much resemble ethical egoism (a view that
Frankena describes as the belief that “one is always to do what will
promote his {or her} own good”—Frankena 1973:15).
Concepts of goodness are generally much more helpful than principles
in determining goals for clients and evaluating therapy outcome.
Unfortunately, ethicists and therapists alike have neglected concepts of
goodness in the twentieth century, although such concepts play a central
role in teleological (consequentialist) ethical theories. When we employ
concepts of goodness, we establish therapy goals and evaluate outcome
because we believe that a particular outcome is good, better than its
alternatives, or the best or ideal psychological end for a client. And so Dr
Peterson established the goal of insight because he believes it is good for
clients like Bob to develop insight. Bob viewed therapy as a success
because at its end he was no longer in a bad (negatively valued) state of
confusion and had achieved the good end of clear thinking and greater
decisiveness.
Taylor argues that we all have “strongly valued goods” in our lives.
We “cannot help,” he argues, “having recourse to these strongly valued
goods for the purposes of life: deliberating, judging situations, deciding
how you feel about people, and the like” (Taylor 1989:59). And it is
primarily (but not exclusively) those goods toward which therapy aims.
And we evaluate therapy outcome by whether clients achieve those good
ends.
Beliefs about goodness play an integral role in teleological ethical
theories because the ethical claims of teleologists are based on whether
goodness is produced, on whether some good or bad end (telos) results.
Accordingly, therapy goals which produce goodness should be chosen,
and the best outcomes are those that produce the best (“most good”)
ends. The nature of the goodness toward which therapy aims is, of
course, critical. Therapists rarely employ the overtly ethical language of
“good” or “bad.” Instead, to denote the goodness to which therapy aims,
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 189
they use words like “successful,” “effective,” “symptom reduction,”
“mental health,” “self-actualization,” and “insight.”
Finally, virtue ethicists evaluate therapy in terms of the ethical
character of therapy clients (cf. Meara et al. 1996; Toulmin 1978; Weiner
1993). For example, to evaluate Bob’s therapy, we can look at the extent to
which he becomes mentally healthy, self-aware, more honest, and so
forth. That is, the extent to which he becomes psychologically virtuous. In
contrast to those who employ principles and judge mental health in
terms of actions, those employing virtue ethics make ethical evaluations
in terms of whether individual persons are mentally healthy (Jahoda 1958).
Although approaches to ethics that employ principles, concepts of
goodness, and virtues can be distinguished conceptually, and it is
sometimes advantageous to focus on one approach for a particular
purpose, at times the three approaches overlap and can be seen as
complementary. For example, humanistic therapy can be evaluated in
terms of concepts of goodness, virtues, and ethical principles. A
humanistic therapist would judge therapy successful if it produces the
good end of self-actualization, or if the client possessed the virtue of selfactualization. And Wolfe suggested that “two moral obligations are
apparent in humanistic therapy”: clients are to “trust in their own
experience” and “refrain from responding to externally imposed moral
standard or, in the current therapeutic patois, ‘one should have no
shoulds'” (Wolfe 1978:47).
The perspectives of clients, therapists, and other therapy
stakeholders
Drawing general conclusions about therapy goals and outcome is
profoundly difficult because stakeholders use different ethical ideals.
Strupp and Hadley (1977) distinguished between the perspectives of
society (which employs the standard of an orderly world of conforming
individuals), the individual (whose value is happiness and gratification
of needs), and mental health professionals (whose standard is “sound
personality structure characterized by growth, development, selfactualization, integration, autonomy, environmental mastery, ability to
cope with stress, reality orientation, adaptation” (Strupp and Hadley
1977:190)).
But Stiles (1983) pointed out that the values of individuals within each
of Strupp and Hadley’s three groups sometimes differ. And so their
evaluations of the goals and outcome of therapy may as well. Not all
clients, for instance, are hedonistic and egocentric. Indeed, some hold
sophisticated ideas about mental health and the well-being of society
(Lambert 1983). Furthermore, identifiable groups of stakeholders within a
society may hold different ethical ideals, and so choose goals and
evaluate outcome in different ways. For instance, the ideals held by a
Health Maintenance Organization and by a patients’ rights organization
190 ETHICS AND VALUES IN PSYCHOTHERAPY
would likely be quite different. Furthermore, therapists from different
schools of therapy choose different treatment goals (Beutler and Bergan
1991), endorse different values (Consoli 1996), and employ different
criteria to evaluate therapy’s effectiveness (Richardson 1989). Therapists’
goals, values, and criteria often arise from differing ethical sources. That,
however, raises one of the most important and thorny questions in this
book: if the goals of therapy are based on conflicting ethical sources, and
therapy’s effectiveness is evaluated in ways that vary with evaluators’
ethical ideals, is psychotherapy (or in what sense is therapy) a coherent
professional practice?
Heterogeneous normality and the prospect of
distinguishing “mental health” from other ethical ideals
Mental health,2 a phrase connoting psychotherapy’s goal and optimal
outcome, has been distinguished from moral values, virtues, and the
entire range of controverted ethical issues discussed in this book. The
promise of doing so: we can avoid dissension by selecting ethically
uncontested therapy goals and by objectively evaluating therapy
outcome. And we can help clients without entering the murky
philosophical waters implied by my claim that therapy goals and
judgments about outcome entail ethical judgments, that therapists
perforce function as ethicists.
Psychotherapists should undoubtedly emphasize psychological goals,
since we are trained to address psychological issues and most clients
assume therapy will focus on them. But I question whether mental health
can be severed neatly from other ethical issues, whether we carve nature
at its joints by sharply distinguishing mental health from ethics.
Addressing that issue well requires a clear and coherent definition of
mental health, preferably one commanding general approval. But we do
not have such a definition.
One reason for our difficulty in defining mental health, and
distinguishing it from ethics, stems from an important fact observed by
Stiles, Shapiro, and Elliott: “Psychological normality is heterogeneous”
(Stiles et al. 1986:171). That is, people free of psychological problems
pursue highly variegated lives, within and across cultures (Marsella and
White 1982; Wig 1990). And so the outcomes of psychotherapy, which
restores people to normality, are also heterogeneous. Awareness of that
fact is, I think, vitally important in understanding the ethical dimensions
of therapy goals and outcome.
Distinctions among mental health and other ideals
Distinguishing mental health from other ideals has a long and
conceptually rich history.3 For instance, Hartmann noted that Freud
“took pains to keep clinical apart from moral evaluation” (Hartmann
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 191
1960:17). Distinguishing clinical and moral evaluations, or mental health
and other ideals, can take two forms: distinguishing mental health from all
ethical considerations (claiming judgments about mental health involve
no ethical issues) and distinguishing between mental health values and
other ethical considerations. Advocates of the latter position
acknowledge the value-laden nature of concepts of mental health, but
assert that we can, and should, distinguish ethical convictions related to
mental health from other ideals. If we do so, some claim, the problems
associated with the role of values in therapy will fade to insignificance.
As Strupp asserted, “to the extent that the therapist’s commitment to
essential therapeutic values is realized a number of issues that are
frequently discussed in the therapy literature become more or less
irrelevant” (Strupp 1980:400).
I will devote my attention to the latter position because I think all
concepts of mental health draw to some extent upon ethical assumptions.
As I argued in Chapter 7 and earlier in this chapter, the concept of mental
health combines psychological and ethical (and often medical)
considerations. It has to do with facts about how human beings function
psychologically, but also with ideals about how human beings best
function, or should function. And so mental health is a “hybrid” concept,
consisting of factual and normative assertions (Wakefield 1992b:374). It is
therefore appropriately rooted in both science and ethics. As Jahoda
noted, in selecting a definition of mental health, we thus “have to choose
what seems best among those definitions intermingling value and fact”
(Jahoda 1958: 4). And so in this section I will discuss the legitimacy of
drawing sharp distinctions between mental health values (ethical
convictions related to mental health) and other ethical convictions. After
clarifying some ways in which distinctions have been drawn, I will
propose a spectrum of understandings of the psychological-ethical
concept of mental health.
Hartmann (1960) gave classic expression to a sharp distinction between
mental health values and other ethical convictions. “In his {or her}
therapeutic work,” he asserted, a therapist:
will keep other values in abeyance and concentrate on the
realization of one category of values only: health values. They are
given special consideration in his [or her] work; they are taken for
granted; and every therapist will, in his [or her] therapeutic work,
consider their realization in his [or her] patients as his {or her}
immediate and overriding concern.
(Hartmann 1960:55)
Distinguishing mental health values from therapists’ more general ethical
convictions requires a clear definition of mental health, of the goal toward
which therapy aims. Identifying a definition to which all therapy
192 ETHICS AND VALUES IN PSYCHOTHERAPY
stakeholders give ready assent has, however, proven extraordinarily
difficult. Nevertheless, some attempts have been made: Margolis (1966)
argued for autonomy, “the capacity of the patient to change his [or her]
beliefs and actions freely” (Margolis 1966:123). And Strupp contended
that “a major—perhaps the major—tenet of modern psychotherapy” is
Freud’s conviction about therapy’s purpose: “to strengthen the patient’s
adaptive capacities, to provide whatever assistance may be necessary to
enable the patient to lead a more satisfying life as a responsible citizen in
our culture” (Strupp 1980: 397). As noted earlier, however, critics of
autonomy have pointed to its heavily Western and individualistic
character and urged that autonomy be balanced with other ethical ideals.
Freud’s views have also failed to receive universal acclaim, especially if
understood to mean that clients should quietly “adapt” to a pathogenic
family or subculture.
Jahoda attempted to identify a consensus about the meaning of
positive mental health. She failed. She did, however, identify six
categories of concepts used to define mental health, all abstract and all
with heterogeneous subtypes. Various theorists, she argued, hold that
mental health has to do with a person’s attitudes toward self; growth,
development, self-actualization; integration; autonomy; perception of
reality; and environmental mastery (Jahoda 1958:23).
Others have identified mental health values associated with particular
theoretical persuasions. In his Operational Values in Psychotherapy, Glad
suggested that patients in successful therapy “integrate themselves in the
terms provided by the therapist—leader” (Glad 1959:302). That is, clients
“grow” into the value-laden normality to which their therapist’s
convictions point. According to Glad:
Psychoanalysts enhance a genital-parental integration…. Clientcentered therapists promote emotional understanding, selfacceptance and awareness of others…. Interpersonal therapists
facilitate skill in social relations, consensual validity and
interpersonal security…. Dynamic relationship therapists nurture
pride and satisfaction in one’s unique autonomy.
(Glad 1959:302)
Employing empirical methods to investigate mental health values, Jensen
and Bergin (1988) found substantial consensus among therapists, as did
Haugen, Tyler, and Clark (1991) and Kelly (1995a). Jensen and Bergin
found that therapists diverged on values related to sex and religion,
however. And Consoli (1996) found that mental health values varied by
therapists’ theoretical orientation. Tyler and Suan (1990; Suan and Tyler
1990) found that some mental health values varied across racial groups,
while Jensen and Bergin (1988), and Tjeltveit, Fiordalisi, and Smith (1996)
found that some mental health values varied with some dimensions of
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 193
respondent religiousness. Finally, Minsel, Becker, and Korchin (1991)
found that “culture carriers” gave descriptions of “positive mental
health” that varied across cultures and age levels. Some overlap
concerning mental health values thus exists among therapy stakeholders,
but not complete consensus.
Furthermore, empirical studies, while helpful for other research
purposes, contribute but modestly to the task of determining whether
mental health values can be sharply distinguished from other ethical
considerations. Because those studies of necessity define “values” in
psychological terms, they can tell us what therapists and other
stakeholders believe regarding mental health values, but not what it
would be ideal for them to believe, or what they should believe.
Smith found little hope that agreement about a conception of mental
health could be reached. And so he suggested that we should no longer
consider it a theoretical concept, but a label for “a variety of evaluative
concerns” (M.B.Smith 1961:300). He also argued that ethical
considerations play a legitimate role in conceptions of mental health. His
laudable awareness of the valid role played by ethical convictions in
concepts of mental health and of the considerable variety of, and conflicts
between, such concepts was, however, followed by a non sequitur: “I
question, secondly, whether there is any profit in the argument about
which evaluative criteria…are to be included.” That kind of skeptical
anti-intellectual flight to inarticulacy and covert ethical conceptions of
mental health has, regrettably, often been emulated. Few therapists
reflect systematically on the ethical character of therapy goals, although a
few philosophers (e.g. Engelhardt and Spicker 1978) have done so.
Follette, Bach, and Follette (1993) expressed a common attitude. They
acknowledged the role played by values in conceptions of health, but
concluded that “there is little basis for deciding whose values are the
‘right’ ones without resorting to dogmatism…if others choose different
values about what should constitute psychological health, the therapeutic
landscape will be all the richer for it” (Follette et al. 1993:305). Trapped
within the hackneyed false dichotomy of absolutistic dogmatism and
relativism, they chose the latter. And so failed to explore the rich middle
ground between those poles, failed to gather its plentiful harvest.
We will also fail to make optimal progress if we pursue two other
approaches to understanding the relationship of mental health and
ethics. First, a sole focus on identifying a consensus about mental health
will not adequately resolve the ethical problems of identifying optimal
therapy ideals and distinguishing appropriately between mental health
and other ideals. Suppose we identify a consensus. The crowd may be
wrong. And, as I noted above, ethicists distinguish ethics from custom
and consensus. Consensus is often relevant to, but does not fully
determine, ethical judgments. Indeed, in light of the heterogeneity of
normality, the diversity of ethical convictions within and between
societies, and the logical link between mental health and contested
ethical assumptions, we should expect concepts of mental health to diverge
194 ETHICS AND VALUES IN PSYCHOTHERAPY
rather than to converge. The failure of therapy stakeholders to recognize
this has prevented the kind of rigorous ethical analyses necessary to
adequately understand and address the ethical character of therapy goals
and outcome.
Second, therapy stakeholders may inappropriately conflate mental
health and ethics, especially when they do not understand the full range
of viable ethical alternatives, when they fail to recognize the
heterogeneity of normality, and when they equate mental health with
their own ethical views. As Roazen notes, therapists can take “rather
striking moral positions…via clinical categories without any awareness
that the same categories might justify very different moral alternatives”
(Roazen 1972:202). And so therapists can use “mental health” (at times in
uncritical ways) to further particular ethical or political causes, to
delineate one region within the heterogeneous realm of normality as the
sole or best region for those seeking mental health. Doing so is not new
(Engelhardt 1978). The concept of self-actualization, for instance, dates
back to the ethical writings of Socrates, Plato, and Aristotle (Franck 1977;
Norton 1976). And Nussbaum noted that many of the ideas and practices
of Hellenistic ethicists anticipated psychoanalysis, with one notable
exception: “Psychoanalysis has not always been willing to commit itself
to a normative idea of health” (Nussbaum 1994:26). Ironically, then, some
psychoanalysts may have pushed the explicitly ethical from
consciousness.
A spectrum of psychological-ethical concepts of mental health
I want to turn now to a constructive proposal for understanding various
perspectives on the relationship between concepts of mental health and
other ethical ideals: psychological-ethical concepts of mental health range
along a spectrum, from mental health as freedom from serious
psychological problems (mental disorders) to freedom for some state of
positive mental health. Concepts of positive mental health range from
limited (“minimalist”) criteria for determining therapy goals or
evaluating outcome, to criteria that are extensive (“maximalist”), criteria
that fully flesh out the meaning of human flourishing.
Defining mental health as freedom from diagnosable mental disorders
or other serious psychological problems entails a relatively limited set of
ethical assumptions: as a general rule, it is good to be free from the
suffering and other problems associated with psychological problems. It
is good, for instance, to be free from clinical depression. Harm and
dysfunction are always present in mental disorders, asserts Wakefield
(1992a, 1992b, 1997), whose conceptual approach explicitly combines
scientific and ethical considerations. He maintains that harm is an ethical
term pertaining to “harmful consequences for the person,” for example,
distress and disability; dysfunction is a scientific term that refers to “a
condition in which some internal mechanism is not functioning in the
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 195
way it is naturally designed to function,” with “mechanism” denoting
physical, behavioral, psychological, motivational, and other features of
organisms (Wakefield 1992a:233).
But harm and suffering are not necessarily bad. Gewirth, for
instance, argues that if Hermann Goering had felt pain (harmful
psychological consequences) because of his sadistic behavior toward
Holocaust victims, “obviously we would regard this pain as morally
good. Consequently, if the removal of pain is the aim of psychoanalysis,
then this is by no means necessarily a moral aim” (Gewirth 1956:30).
Therefore, although it is generally good to relieve an individual’s distress,
in some circumstances it may not be.
Three other ethical complexities are tied to mental health as freedom
from psychological problems. The first can be seen in Wakefield’s (1992a)
concept of harmful dysfunction. He asserts that human beings have some
kind of “natural design” in accord with which we function when not
disordered (i.e. in accord with which we ideally, or should, function).
This contention rests on scientific findings, philosophical assumptions
(historically often tied to particular understandings of science), and an
ethical assumption, an assumption that, although often linked with
science, is neither a scientific finding nor intrinsic to the scientific
method. That ethical assumption is that it is good to, or we should,
function in accord with the way nature has designed us to function.
Although science can clearly provide us with some knowledge about our
nature (albeit not at the level of metaphysics, e.g. whether our nature is
nothing but material and fully amenable to scientific explanation;
Christopher 1996; R.B.Miller 1983; Tjeltveit 1989), science cannot tell us
that it is good that we function in harmony with our nature, or that we
should.
Second, freeing someone from a psychological problem (a relatively
uncontroversial therapeutic goal) may produce ethically relevant
consequences or conflict with some ethical obligation. Suppose the good
end of reducing Bob’s depression can be reached in two ways: quickly
reducing it by dramatically reducing the time he spends with his three
children (which would harm his children and conflict with his obligation
to them) or reducing his depression more slowly by addressing his
maladaptive cognitions and expanding his limited repertoire of coping
skills (which would permit him to continue to spend ample time with his
children). In that case, the choice of treatment goal clearly involves, not
simply Bob’s freedom from mental illness, but broader ethical issues as
well.
Finally, although therapists may wish to limit their influence on
therapeutic outcome to eliminating psychological problems, it is hard in
practice to move people from those problems without also moving them
to some new state, producing an outcome that can be evaluated ethically.
Clients working with therapists who consciously limit their influence to
eliminating psychological problems may develop a particular form of
positive mental health, the implicit or explicit vision held by their
therapist. Therapy’s de facto outcome may thus be a modestly rich set of
196 ETHICS AND VALUES IN PSYCHOTHERAPY
ethical assumptions about mental health, about the good life, even when
therapists strive only to free clients from their psychological problems.
Concepts of positive mental health (mental health as freedom for
some good end) are based on more extensive sets of ethical convictions
(Engelhardt 1978) and are even more controversial (Smith 1961). And
maximalist (extensive) concepts of mental health are more controversial
than minimalist (limited). Although no sharp line can be drawn between
minimalist and maximalist concepts, the extremes of the continuum can
be differentiated. Parloff, for instance, distinguished between therapists
who “are not interested in tampering with the value systems of their
patients” and those “willing to accept the responsibility of advocating
particular values as being those that foster mental health” (Parloff 1967:
14). In the maximalist category may be found the World Health
Organization’s definition of health as “a state of complete physical,
mental, and social well being and not merely the absence of disease or
infirmity” (World Health Organization 1981:83), Nicholas’s (1994) telling
her client that he cannot possibly become mentally healthy while selling
marijuana, Doherty’s (1995) promotion of “ethical empowerment” for
clients, and Ellis’s aspiration to produce in clients a “profound
philosophic change” (Ellis 1987b:473).
Minimalist convictions, by way of contrast, generally stick closely to
clients’ stated goals and therapists’ training. For instance, if Bob has
psychological problems because he does not have the skills to cope with
his marital separation, a therapist who establishes “improved coping
skills” as a therapy goal would likely receive little criticism. But some
therapists would think that to be a paltry, insufficient goal, and others
would emphasize other goals. As noted above, however, even minimalist
concepts, like Freud’s emphasis on adaptive capacities (Strupp 1980), have
been criticized. This is partly because modest sets of ethical ideals are
often tied to more extensive sets of ethical convictions. For example,
Freud can be viewed as espousing the minimalist ideals of adaptation or
of “love and work” (Fine 1990). But more extensive ethical commitments
were sometimes evident, as in his caustic attack on the moral obligation
to love one’s neighbor as oneself (Wallace 1986). Accordingly, as is true
of concepts of mental health as freedom from psychological problems,
minimalist concepts of positive mental health are ethically laden.
Evaluating concepts of mental health and mental health-ethics
distinctions
A variety of mental health definitions and distinctions between mental
health and other ethical ideals can be defended. Advocates of each face
particular conceptual and practical challenges; each working answer to
these thorny issues requires ethical justifications and a translation from
the realm of the theoretical to that of the practical.
Those arguing for concepts of mental health that involve more
extensive ethical commitments have, I believe, a greater responsibility to
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 197
justify their concepts of mental health than those whose concepts of
mental health bear a more modest ethical content. The burden of proof is
on therapists holding maximalist views. They need to justify why they
should venture beyond their training (unless they have relevant
education or experience) and the customary societal agreement regarding
therapy. And they face the challenge of addressing deep disagreements
about the nature of human well-being and flourishing in many cultures
and among ethicists (MacIntyre 1984) without slipping into either
relativism or absolutism. Finally, therapists need to be very careful when
working with clients who do not share their ethical views, lest
therapeutic alliances suffer or clients be influenced inappropriately
(Tjeltveit 1986).
Those holding minimalist concepts of mental health, and especially
those who define mental health as freedom from psychological disorder,
face other problems. They may implicitly introduce richer ethical
concepts into their assumptions about therapy goals, and so covertly
influence clients. Or, anticipating a theme to be addressed later in the
chapter, the overall impact of their “minimalism” may be a problematic
individualism and a diminution of clients’ relationships with others. In
addition, therapists who aspire to limit their interventions to mental
health values (conceived in minimalist terms) face the difficult task of
differentiating mental health from other ethical ideals. As Odell and
Stewart (1993) note, some would think a feminist therapist who endorses
non-traditional family roles is advocating health values, but others moral
values.
The greatest virtue of minimalist concepts of mental health is their
consistency with the training therapists receive and with implicit societal
contracts about the role of therapy. Wallace provides an exemplary
account of a modest vision of the role of the professional:
Primum non nocere, the prevention of untimely death where possible,
the reduction of gratuitous pain and suffering, the amelioration of
disability, the competent and compassionate care of the chronically
and terminally ill, and better cognizance of the place and role of the
social surroundings in disease and illness are all sufficiently noble
aims for a healing profession. The inculcation of happiness,
contentment, values, virtue, wisdom, Weltanschauung, creativity,
and a passionate sense of vocation, on the other hand, are beyond
doctors’ consignment and competence. With quietly realistic goals
we may at most, by helping patients with impediments to fuller
exercise of their capacities, enable some, if personal endowment and
subsequent fortune permit, to obtain such desirables more than
otherwise.
(Wallace 1991:110)
198 ETHICS AND VALUES IN PSYCHOTHERAPY
Mental health as moral or nonmoral, obligatory or ideal
A final issue pertaining to the possibility of distinguishing mental
health from other ideals needs to be addressed: whether mental health
pertains primarily to nonmoral ideals, or bridges moral and nonmoral
ideals. The distinction, a controversial one discussed in Chapters 2 and 4,
appears in Hartmann’s (1960) classic distinction between moral values
and health values. In his schema, health values are nonmoral values.
Because one traditional way to distinguish moral from nonmoral is to
consider obligation the “basic moral notion” (Annas 1991:330), the
question of whether mental health pertains to moral or nonmoral ideals is
often tied to that of whether mental health ideals are considered
obligatory or merely aspirational.
Because my definition of ethics includes both moral and nonmoral
considerations, and both obligations and aspirational ideals, I frame the
issue in this way: does therapy’s ethical character have to do with
nonmoral and aspirational ideals, with moral and obligatory ideals, or
with both? Hartmann’s distinction implies that appropriately conducted
therapy pertains to nonmoral and aspirational ideals alone. I think
therapy has to do with moral and obligatory ideals as well, but is more
concerned with nonmoral and aspirational ideals. For example, it would
have been good for Bob to develop insight; that was an aspirational ideal.
But it was not obligatory for him to do so. We would not say he should
have done so, or that it was immoral or wrong that he did not.
There may be some situations, however, in which therapy goals
involve moral obligations. If, for instance, a father is court-ordered into
therapy secondary to neglecting or abusing his children, therapy goals
would include stopping the abuse and neglect and his becoming a better
father. Those goals are moral and obligatory, not merely aspirational. It
would be wrong for him to fail to become a good father if doing so was
within his grasp.
In addition, moral and nonmoral considerations sometimes conflict in
therapy. In the case study in Chapters 4 and 5, for example, Sandra
wanted (established as her therapy goals) to continue to take care of her
invalid father (which she believed was her moral obligation) and to be
less depressed (a nonmoral good). Sandra’s therapist, in establishing
goals for her therapy, could focus solely on decreasing her depression.
But if doing so conveyed to Sandra that that nonmoral good was of
greater importance than the moral good of caring for her father, the
impact may be moral, not merely nonmoral. A third alternative would be
to help Sandra find a way of living that could preserve her commitment
to her father yet be less depressed. But that goal, because including her
moral obligation to care for her father, would mix moral and nonmoral
considerations.
And so the moral-nonmoral and the obligatory—aspirational
distinctions have some merit, but they can be hard to draw, and therapy
often involves both. When therapy involves both, mental health can
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 199
appear to conflict with other ethical ideals. That and other conflicts
between ideals will be addressed in the final section of the chapter.
Conclusion
All therapeutic ideals are, in part, ethical. Mental health values can be
distinguished from other ethical ideals, but not distinguished sharply.
Although mental health and other ideals are defined in many different
and often overlapping ways, and are related in a variety of ways, mental
health ideals bear at least a family resemblance to one another.
Accordingly, I define mental health ideals as a congeries of more or less
related ethical ideals that pertain in some way to the elimination of
psychological disorder, to optimal psychological functioning, or to both,
and that are primarily (but not exclusively) nonmoral.
Distinguishing mental health from other ideals is helpful because
psychotherapy professionals should focus their attention on
psychological functioning. The use of the phrase “mental health” and
other terms emphasizing that ideals are psychological reinforces that
distinction and serves to delimit therapy’s scope. The specific ways in
which mental health is distinguished from other therapy ideals will
depend in part, of course, on the particular concepts of mental health and
the other specific ideals being employed.
In this section, I have set forth a spectrum of concepts of mental health,
ranging from reducing psychological disorders to extensive sets of ethical
ideals. And I argued that a greater burden of proof falls on those whose
concepts of mental health include extensive ethical content, are at
variance with the cultural contract regarding psychotherapy, or both.
Whatever definition of mental health one employs, however, careful
ethical analysis of concepts of mental health is helpful, analysis that
eschews relativism and absolutism. This need for ongoing ethical
analysis is one reason, however, that a distinction between mental health
and other ethical ideals will not function as some of its advocates have
desired: it will not free therapists from the responsibility to engage in
careful ethical reflection about the goals and outcome of therapy.
Distinguishing mental health from other ideals will also not free
therapists from ethical reflection because concepts of mental health are
heterogeneous, a reflection of the underlying ethical differences and the
heterogeneity of normality that are present in contemporary societies.
That reality (and the variety of ideals held by other therapy stakeholders)
means we can expect ongoing debate about the ethical character of
therapy. We face multiple ideals, a diversity of valued therapy goals and
outcomes.
200 ETHICS AND VALUES IN PSYCHOTHERAPY
Level of abstraction
Therapy goals vary in level of abstraction. Goals for Bob’s therapy, for
example, can be stated in increasingly abstract terms, from “able to
dispute depressogenic thoughts” to “decreased depression” to “mental
health.” Those striving to ethically evaluate goals or outcome need to
clarify the level of abstraction at which a goal is stated, especially when
apparent disagreements exist (e.g. between therapists and clients or
between therapists and third-party payers). Agreement is more likely at a
middle level of abstraction—between the very specific and the very
abstract (Browning and Evison 1991; Neimeyer 1993; Saltzman and
Norcross 1990)—and when those discussing therapy goals and outcome
do so at the same level of abstraction.
When level of abstraction is ignored, apparent agreements about
therapy goals or outcome may mask underlying differences. For
example, Lambert noted that those who agree that divorce is a poor
outcome may disagree at a deeper level. Freudians may point to the
individual’s intrapsychic “failure to maintain a satisfying, intimate
relationship with a person of the opposite sex (resolving the Oedipal
complex)” (Lambert 1983:25). But others think divorce a poor outcome
because it harms family members. Likewise, the goal of autonomy can be
affirmed for very different reasons (Taylor 1989)—because persons are
“disengaged subjects,” are purely rational agents, are Selves whose
nature is being actualized, or are created, sinful, and liberated children of
God (in Jewish or Christian understandings of human beings). One
ethical ideal, autonomy; many underlying understandings of human
beings and the good life.
The reverse can occur as well: apparent disagreements can dissolve
when two parties begin speaking at the same level of abstraction. If Bob
states he wants to be less depressed, and Dr Peterson states he wants Bob
to develop greater insight, the apparent disagreement may be resolved by
Dr Peterson talking at Bob’s level of abstraction and affirming that he, too,
wants Bob to be less depressed.
Tailoring goals to the individual, context, and culture
Some therapy stakeholders establish therapy goals and evaluate outcome
in terms intended to apply universally, to everyone seeking therapy, or at
least to everyone meeting certain criteria (e.g. diagnostic). For example,
“It would be good if everyone became self-actualized.” But others tailor
goals to particular clients, contexts, and cultures and evaluate the outcome
accordingly. Parloff distinguished, for example, between mental health as
“the highest level of functioning of which mankind is capable” and mental
health as “the full utilization of the individual patient’s unique capacities”
(Parloff 1967:13). Those conflicting approaches stem, in part, I think, from
an unresolved conflict about individuality in the West, a conflict traced
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 201
by Taylor to Descartes and Montaigne. The former sought to draw upon
universal criteria and reason; Montaigne aimed instead for “each
person’s originality” (Taylor 1989:182). Many, of course, affirm both. An
emphasis on universal goals and an emphasis on tailored goals may thus
both exist on continua, with varying degrees of support for each.
Furthermore, those emphases can be combined in various ways. Beutler
and Clarkin (1990), for example, argue that therapists should employ
those specific treatments that have been proven effective for a particular
problem. They thus argue for goals (understood at a middle level of
abstraction) that are universally applicable (as established by research) to
decrease the symptoms of individuals with particular problems.
Most therapists tailor goals to the needs of individual clients, thinking
it would be good for one client to develop greater assertiveness but good
for a second to develop greater sensitivity to the needs of others. Insight
may be a goal when a client is psychologically minded; behavior change
when clients’ actions are producing harm. There is no reason to expect
one kind of “improvement,” Stiles, Shapiro, and Elliott (1986) suggest,
because client needs and aspirations differ. If normality is heterogeneous,
goals will be as well: different clients will strive to eliminate their
problems and reach different types of normality. Goals are thus
improvised for each new client and revised as their situation and desires
change. Therapists who claim to tailor goals to the individual may,
however, regularly establish the same family of goals, implicitly
assuming the goodness, rightness, and/or virtue of those goals applies to
all clients.
Therapy’s context may also be important in setting goals. Before
deciding whether to encourage a woman to assert herself with her
husband, for instance, it is important to know if she is living with a
batterer and has no alternate living situation. As Hartmann pointed out,
adaptation as treatment goal can only be defined “with reference to
specific environmental settings” (Hartmann 1939:318).
Goals may also need to be tailored to cultural context (Marsella and
White 1982), at least to some extent. Varma (1988), for instance, suggests
that Western forms of therapy be modified for clients in India to deemphasize autonomy and emphasize interdependence. And Dwairy and
Van Sickle (1996) argued that the traditional goals of Western
psychotherapy, self-realization and self-integration, be adapted in light of
Arabic condemnations of those ideals and Arabic commitment to
collective identity.
Tailoring goals to individual, context, and culture can be done either
relativistically or non-relativistically. I argue for the latter, asserting that
we need not give up the conviction that there are some universally
applicable ethical truths to alter therapy goals to some degree to meet
individual needs. Goals can be, should be, tailored to some extent, but
broad patterns of ideal human functioning can still be identified. Paying
close attention to the level of abstraction is important in this connection;
universally applicable ethical truths occur at some levels, with cultural
202 ETHICS AND VALUES IN PSYCHOTHERAPY
differences occurring at other levels. For example, parental care for
children is a cross-cultural ideal that finds expression in different ways
across cultures.
Extent of ideals
Therapy stakeholders differ dramatically in the abundance of their ideals
about therapy. Some possess few thoughts about therapy goals and
outcome. Clients may simply want to feel better, to suffer less. Or they
(and other stakeholders) may have extensive sets of ethical convictions,
convictions about ethical issues in general, about psychotherapy goals
and outcome, or both. Herron, Javier, Primavera, and Schultz (1994)
distinguished between three levels of therapy goals: necessity,
improvement, and potentiality. Third-party payers are willing to address
the first and possibly second levels, but not the third. Those levels
correspond roughly to mental health as freedom from psychological
disorder, as minimalist positive ideal, and maximalist positive ideal.
Some therapists and clients raise topics in therapy that are broader than
mental health. Doherty (1995), for instance, aspires to empower clients
ethically. Therapy goals and outcome may thus address a full range of
moral, spiritual-religious, and political convictions.
The extent of therapist ideals does not generally become evident in the
early stages of therapy, when therapists focus on understanding and
accepting clients, and a de facto moratorium on addressing ethical issues
is commonly in effect. Rather, the full range of a therapist’s convictions is
more likely to emerge later in therapy, during what Browning called the
“stage of reaggregation” (Browning 1987:92). Late in therapy, clients
rethink their understanding about “the good life,” their approach to life,
their “rules for living,” and thus their ethical convictions. An extensive set
of therapist ideals may then powerfully influence clients.
But therapists who hold and convey a minimal set of ideals may also
significantly influence the ethical convictions of clients. Bob, for example,
used Dr Peterson’s minimalist “take better care of yourself’ as a working
ethical rule. Applying that ethical principle, he decided to divorce his
wife and significantly reduce his commitment to his children. Even
minimal therapist ethical convictions about ideal human functioning can
thus profoundly affect clients living by ideals that are more extensive.
Specific ethical ideals
I now want to turn from the very general terms in which I have been
discussing ideals to a consideration of the specific ideals that different
therapy stakeholders employ when they propose, choose, and evaluate
psychotherapy goals and outcomes. In this section I want to highlight
some key issues pertaining to therapy ideals, then address the breadth of
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 203
specific principles, concepts of goodness, and virtues used to formulate
therapy goals, evaluate therapy outcome, or both. I will address
outcomes intended by stakeholders (e.g. “mental health”) and outcomes
that are not so intended (e.g. negative effects on clients and family
members). I include the latter because unintended consequences are
sometimes ethically relevant.
A wide range of therapy ideals has been proposed, at times in the
absence of thoughtful engagement with, or even acknowledgment of,
alternatives. Some ideals are phrased in positive terms (e.g. “autonomy is
a good therapy goal and outcome”) and some in negative terms (e.g. “it is
not good that therapy produces politically passive citizens”). Those
phrased in negative terms draw upon some positive ideal. For example,
complaints about therapy producing political passivity draw upon the
conviction that active political involvement is good or obligatory.
Some specific ideals apply to all therapy relationships. Others are
associated with particular schools of therapy (e.g. a devotee of Skinner
would not affirm autonomy as a therapy goal, at least those forms of
autonomy rejected by Skinner in Beyond Freedom and Dignity). Still other
specific ideals apply only in particular therapy relationships. Because
various therapy stakeholders make claims about the applicability of
specific ideals at each of those levels, I will address all three.
Psychotherapy outcome is traditionally evaluated by comparing a
client’s functioning at the beginning with the client’s functioning at the
end of therapy. A good outcome is one in which valued ideals have been
reached; a poor outcome is one in which those ideals have not been
reached. Such evaluations are important, and should continue.
Two aspects of that traditional approach are notable: short-term outcome
is generally evaluated (at the time of termination and, occasionally, at a
later follow-up, rarely exceeding five years). And only the effects of
therapy on the individual client are typically considered. One root of that
short-term and individualistic emphasis, I suspect, is therapists’
commitment to codes of professional ethics, and especially the tradition of
the Hippocratic Oath. Its core ethic, Veatch maintains, is that the
professional “benefit his {or her} patient” (Veatch 1978:173). The focus is
on the well-being of the patient, not the common good. For those
concerned about the general welfare, medicine and other professions
should be supported if that professional concern for individuals benefits
society. Documenting the benefits of medicine to society is not difficult.
The negative impact of those few rogues who, when restored by the
physician to full physical health (normal physical functioning), harm
society is more than outweighed by the positive impact of others who,
when restored to physical health by physicians, contribute to the wellbeing of society.
Psychotherapy’s positive contributions to society are easily established
when therapy’s goal is eliminating serious psychological dysfunction.
Justifying therapy is more difficult, however, when its goal is some
positive psychological ideal. This is true in part because psychological
204 ETHICS AND VALUES IN PSYCHOTHERAPY
normality is heterogeneous in ways physical normality is not and in part
because the definition of positive mental health is disputed. Some
therapy outcomes may produce short-term benefit for a client, but longterm harm. And some client changes may benefit the client but harm
other people.
To address the full range of consequences of therapy and to counteract
what I think are some blind spots of the traditional approach to
evaluating therapy outcome, I suggest that proposed ethical ideals for
therapy should be subjected to three tests: impact on the individual,
impact on others, and long-term impact.4
This proposal contrasts with traditional psychotherapy and medical
training, which focuses on the individual client. I am proposing instead
that ethical evaluations of therapy ideals include an alternation between
reflecting on particular persons seeking help and reflecting more
broadly. That broad reflection should include these questions: in what
kind of society, in what kind of global human community, with what
kind of human functioning, would we like to live in ten years? in fifty? In
other words, what would be the best outcome for humanity? And in
what relationship do therapy goals (and actual outcome) stand to the
answers given to those questions?
In light of those questions, the phrases I have been using—“choosing”
goals but “evaluating” outcomes—need to be reconsidered. We need, in
part, to choose desired (good, better, best, ideal, right, virtuous) outcomes,
then establish the goals that are most likely to produce those outcomes.
I am under no illusion that we will soon develop a cross-cultural
consensus about long-term social and individual ideals relevant to
therapy. Indeed, given the heterogeneity of normality, ethical differences,
and crosscultural variations, I am confident that such a consensus will
not be forthcoming.
Despite that lack of a consensus, I think it important to reflect on the
long-term and social effects of therapy, for two reasons: to develop better
therapy ideals and to consciously articulate ideals.
Reflection about therapy ideals can produce some outcomes that are
better than others, and can identify some distinctly undesirable outcomes
(e.g. an authoritarian state or a society of individuals concerned only
about themselves). Those outcomes would be viewed unfavorably in part
because leading to short- or long-term negative outcomes for individuals,
families, communities, societies, or the entire human community.
Second, our failure to reflect on the long-term and social effects of
therapy will not prevent such effects from occurring; rather, those effects
will simply be unplanned, and our goals implicit and covert. Therapy
stakeholders can either let those effects occur without reflection, or
submit them to critical scrutiny and translate their conclusions into
therapy goals. Third-party payers, it should be noted, do engage in longterm scrutiny. Using the criterion of expense (with high expense
considered bad), they set financial goals relative to therapy (to control
therapy’s financial outcome). Therapists employ other kinds of socially
oriented reasoning to justify therapy to third-party payers (justifying
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 205
therapy in terms of how it reduces medical expenditures and otherwise
contributes to the well-being of society). But given the variety of therapy
ideals and the heterogeneity of normality, the key issue for the future
will not be therapy versus no therapy, but which kind of therapy, for
which purposes, and toward which ideal ends. To address those issues, we
will need to consciously articulate therapy ideals.
A hotly contended question prompted my posing the question of the
social and long-term effects of therapy: is the social cost of psychotherapy’s
focus on the well-being of individuals too high? Or, as Bellah, Madsen,
Sullivan, Swidler, and Tipton (1991) put the problem, “Are we
responsible only for our own good or also for the common good?” (Bellah
et al. 1991: 81). Individualism has been attacked (e.g. Bellah et al. 1985,
1991; Fox-Genovese 1991; Sampson 1988), with calls to move “beyond
individualism” (Callahan 1988; Crittenden 1992; Gelpi 1989; Hermans et
al. 1992; Piore 1995; M.B.Smith 1994) and “beyond self-interest”
(Mansbridge 1990), to “reconstruct individualism” (Heller et al. 1986), and
to understand individualism’s historical origins and how deeply it is
rooted in Western culture (Stam 1993). But some understandings of
individualism and authenticity have also been defended (Taylor 1992;
Waterman 1984). The debate is ongoing.
With those considerations highlighted, I want to address ideals
pertaining to therapy, considering in turn principles, concepts of
goodness, and virtues.
Principles
An ethical principle, for example, an individual’s responsibility to others,
can serve as a criterion to determine or evaluate desired ends (the goals
or outcome of therapy), as the desired end itself, or as both. A successful
outcome would thus be a client exhibiting greater responsibility for
others, believing he or she should do so, or both. Mahoney, for instance,
talked of our “collective responsibilities” (Mahoney 1991:4),
responsibilities tied reciprocally to individual lives. And Doherty speaks
of “clients’ responsibilities for, and obligations to, their communities”
(Doherty 1995:97; cf. Boszormenyi-Nagy 1987). Doherty also affirms the
ethical obligations of commitment, justice, truthfulness, and community,
obligations that apply to clients. He asserts that therapists working
ethically with clients can (and at times should) address those obligations
in therapy.
Ethical principles (obligations) play a different role in therapy when
therapists reject clients’ principles and/or strive to minimize their
adherence to them (e.g. when therapists strive to replace clients’
“obligations” with “preferences” and their “shoulds” with “wants”).
Freud’s hostility to Christians who asserted that people have a moral
obligation to love their neighbors (especially when involving selfsacrifice), for instance, no doubt had the effect on some of his clients (and
206 ETHICS AND VALUES IN PSYCHOTHERAPY
on clients of those who share his ethical views) of reducing their belief in
those ethical principles. The reasons Freud opposed that obligation are
instructive. Wallace notes two: Freud thought it “psychologically
unworkable and maladaptive for the individual,” and the injunction
“cheapened an individual’s love for family and friends” (Wallace 1986:
100). The superego, Freud asserted, must be opposed because “in the
severity of its commands and prohibitions it troubles itself too little about
the happiness of the ego” (Freud 1961:90).5 In the terms I am using, a
concept of goodness (the ego’s happiness) trumps an ethical principle
(loving one’s neighbor).
Therapists vary, of course, in their affirmations and rejections of ethical
principles—across schools of therapy (with Freudians, for example,
generally more willing to “lower the demands of the superego” than
adherents of reality therapy—Glasser 1965), across therapists, and across
therapeutic relationships with different clients. As an example of the last,
some clients may well be so “tyrannized by shoulds” that even therapists
with extensive sets of moral beliefs would challenge (try to moderate)
those clients’ feelings of moral obligation.
Debates also occur between those holding that people (including
clients) have obligations to control and inhibit their impulses, and those
(therapists and others) who either eliminate the category of obligation
entirely or encourage clients to identify and express their impulses and to
get their needs met. And, of course, most therapy stakeholders occupy
some middle position between those extremes.
Humanistic therapists, in the view of Wolfe (1978), see clients in
successful therapy as dropping most ethical principles but adopting two
new “moral obligations”: “to refrain from responding to externally
imposed moral standards” and “to trust in their own experience”
(B.E.Wolfe 1978: 47).
The idea that “Clients will increase their commitment to their
communities and to justice” is a valid goal for psychotherapy, or is a
criterion by which therapy outcome is appropriately evaluated, is foreign
to many therapy stakeholders. The role of therapy in reducing adherence
to “pathogenic” moral principles is more common. Suppose we evaluate
this outcome, “the client’s belief in the ethical principles of justice and
loving one’s neighbor was sharply curtailed,” in terms of my three tests.
If moral principles (obligations) are entirely pathogenic, the effect of that
outcome on individuals in the short- and long-term would be positive.
But if societies need their members to look out for one another and be
committed to the general welfare, and if justice is important to the proper
functioning of a society, therapeutic relationships that undercut clients’
moral convictions about justice and neighbor love will be likely to have
negative long-term societal effects.
Those who conduct ethical analyses of therapy have sometimes
been sharply critical of therapists’ de facto ideals. The critics’ ethical ideals
are evident in the terms they use. They may, for example, think it wrong
to be “selfish” (defined as “1: concerned excessively of exclusively with
oneself: seeking or concentrating on one’s own advantage, pleasure, or
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 207
well-being without regard for others”—Merriam-Webster’s Collegiate
Dictionary 1993: 1060). And so they would criticize therapy outcomes in
which people leave therapy more selfish than when they began.
Unfortunately, from their perspective, therapy has been characterized as
“a process by which nice, normal, neurotic people become more selfish”
(B.E.Wolfe 1978:48).
Concepts of goodness
Therapy ideals are often concepts of goodness rather than ethical
principles or virtues. Effective therapy is seen to produce some good end;
ineffective or destructive therapy fails to produce a good end or increases
some bad (negative, harmful, not good) end. Therapy ideals are rarely
discussed in the explicitly ethical language of goodness, however. An
exception is Nicholas, who asserted that therapists “must, when possible,
consciously work toward fostering goodness” (Nicholas 1994:224).
Contemporary therapists affirm a variety of goods. The Mental Health
Values Questionnaire of Tyler, Clark, Olson, Klapp, and Cheloha (1983),
for instance, includes ninety-nine values (Haugen et al. 1991).
Respondents indicate whether values like “The person is able to forgive
other people for their mistakes” (Tyler et al. 1983:23) are indicative of
“healthy emotional functioning” (Haugen et al. 1991:25). Jensen and
Bergin (1988) included sixty-nine items on their measure of values
pertaining to mental health, E.W.Kelly (1995a) included fifty-three, and
Consoli (1996) forty-three. In each case, the authors considered other
proposed good ends for therapy before arriving at their lists. When
consulted, philosophers offer conflicting advice. As Rescher (1969) noted,
the Cyrenaics emphasized the good end of pleasure, for Aristotle it was
happiness,6 for Plato, knowledge, the Stoics emphasized virtue, Kant a
good will, and the utilitarians concentrated on the general welfare.
As a rule, therapists neglect certain concepts of goodness that have
been affirmed throughout history (Gettner 1978; J.D.Frank 1973, cited in
Wolfe 1978). Concepts which therapists pass over when setting goals and
evaluating therapy outcome include “the redemptive power of suffering,
acceptance of one’s lot in life, filial piety, adherence to tradition, selfrestraint, and moderation” (J.D.Frank 1973, cited in Wolfe 1978:48), and
“advancing knowledge, pursuing honor, or creating something of lasting
or absolute value” (Gettner 1978:1060).
In this section, I will map out concepts of goodness related to therapy
goals and outcome. After addressing the goodness of freedom from
negatively valued states (e.g. mental health as freedom from disorder), I
will discuss concepts of goodness related to the self, to relationships, to
balance, and to spirituality.
The good to which therapy aims, many assert, is freedom from some
negatively valued state. It is good, for instance, to be free from crippling
depression, command hallucinations, and panic attacks. Relieving pain
and decreasing suffering are widely affirmed as goods among therapists.
208 ETHICS AND VALUES IN PSYCHOTHERAPY
Most therapy researchers employ such criteria of goodness in measuring
decreases in psychopathology or serious symptoms. And when clients’
pain and suffering are serious and harm is substantial, even third-party
payers and therapists are in accord.
But some forms of pain (e.g. guilt at committing heinous acts) may not
be so bad (Gewirth 1956). And J.D.Frank’s (1973) mention of
“redemptive” suffering points to a long tradition of finding meaning in
suffering. Furthermore, many distinguish between mild levels of
discomfort (normal unhappiness) and serious suffering (Schofield 1986).
Obtaining freedom from the latter is far more important than freedom
from the former. Some who fail to distinguish between the two, however,
may argue that all discomfort should be eliminated, including the guilt
and anxiety that may stem, in part, from holding ethical ideals.
Concepts of goodness pertaining to the self have been the most
prominent positive therapy ideals. This has been both celebrated and
condemned.
Autonomy is the primary good therapists seek for clients. Although
almost all affirm it (Jensen and Bergin 1988), humanistic and
psychoanalytic psychologists stress it. Indeed, Szasz (1965), in a
somewhat idiosyncratic reading of Freud, argued that “the paramount
aim” of psychoanalysis is the “preservation and expansion of the client’s
autonomy” (Wallace 1986:7). This has found an especially resonant
hearing in the US, because “freedom is perhaps the most resonant, deeply
held American value” (Bellah et al. 1985:23).
That it is good for human beings, including clients, to be free from
coercion—from without and from within—seems clear, at least in normal
circumstances. What is less clear is what human beings are to be free for.
And, as commentators have noted, the ways in which freedom is
commonly understood make it difficult to “address common conceptions
of the ends of a good life or ways to coordinate cooperative action with
others” (Bellah et al. 1985:24). But consensus about therapy’s good ends is
precisely what therapy stakeholders need when determining therapy’s
proper goals, limits, and funding. The language of freedom provides no
basis for such discussions. As Guignon noted, unbounded freedom “may
be self-defeating. For where all things are equally possible…no choice is
superior to any others. Freedom then becomes, in Rieff’s {1966:93} classic
line, the ‘absurdity of being freed to choose and then having no choice
worth making'” (Guignon 1993:223).
Other good characteristics of the self—attitudes, beliefs, behaviors,
and emotions—are claimed by stakeholders as the ends toward which
therapy properly aims, or the criterion by which its success or failure is
properly judged. Pleasure is the good state some clients assume therapy
will produce in them, so they will be consistently happy and at peace.
Jahoda (1958) noted that attitudes toward the self, growth, development,
self-actualization, and accurate perception of reality have been linked to
positive mental health. Others emphasize the content or style of thinking.
Ellis and Bernard, for instance, described the good ends toward which
Rational-Emotive Therapy aims, the good ends of these “rational
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 209
attitudes”: “self-interest,” “social interest,” “self-direction,” “high
frustration tolerance,” “flexibility,” “acceptance of uncertainty,”
“commitment to creative pursuits,” “scientific thinking,” “selfacceptance,” “risk-taking,” “long-range hedonism,” “nonutopianism,”
and “self-responsibility for our own emotional disturbance” (Ellis and
Bernard 1985:7–9). All, save the second, pertain primarily to the
individual.
Good behavioral (rather than emotional, cognitive, or attitudinal)
changes in the self are stressed by still other theorists. Assertiveness and
social skills are the good ends, for example, toward which behaviorists
often want clients to move.
The goodness of the self as a self-contained whole embracing a variety
of psychological characteristics is emphasized by still others. Speaking in
general terms, Michels identified as one of psychoanalytic theory’s values
“the significance of the individual as opposed to the collective” (Michels
1987:42). Empirical researchers have found that psychologists more
frequently endorsed individualistic responses, than responses affirming
social embeddedness and responsibility (Fowers et al. 1997), even though
clients in an analogue study did not show any preference between
counselors with a social commitment emphasis and counselors with an
individualistic emphasis (Kelly and Shilo 1991). (Ironically, then,
therapists who favor an individualistic approach may do so for reasons
other than the preferences of individual clients.) Some therapists argue for
self-actualization, self-fulfillment, and personal growth as therapy goals
and as criteria by which to judge outcome. The self is the end toward
which psychotherapy is properly directed. Self-interest is the client’s
proper focus. And, as Stiles, Shapiro, and Elliott note, the personality
theorists summarized in Hall and Lindzey’s (1978) classic personality text
“describe psychological health as involving increases in individual
variation” (Stiles et al. 1986:171). And so the profoundly important,
philosophically and psychologically complex concept (see Taylor 1989) of
the self has been celebrated, with individual risk-taking, creativity,
adventuresomeness, and individuality affirmed. As Berger notes, “selfenhancement is an ultimate goal, as opposed to self-sacrifice in the
interests of enhancing others or society in general” (Berger 1982:83). The
sources of this ideology are manifold, including humanistic psychology’s
metaphysically rich belief in the self’s s “true” nature, Romanticism’s
fervent faith in the rich inner nature of the self, and Nietzsche’s
identification of “self-deification as a human being’s supreme perfection”
(Berkowitz 1995:19).
But others vigorously deny the goodness of the self or, better,
individualistic understandings of the self. M.B.Smith argues that “in
cross-cultural perspective, American culture is really over the edge in its
individualistic ethos, and the costs to people that this extreme orientation
entails are increasingly visible” (M.B.Smith 1990:530). Psychotherapy has
been attacked for fostering selfishness (e.g. Wallach and Wallach: 19837),
navel gazing, egotism, political quietism, self-absorption, self-indulgence,
a neglect of other people, and a host of other ills. Bellah, Madsen,
210 ETHICS AND VALUES IN PSYCHOTHERAPY
Sullivan, Swidler, and Tipton (1985) and Cushman (1995) have argued
that psychology has contributed to the “empty selves” characteristic of
many in the contemporary era. Dominant forms of therapy, the former
work contends, cannot provide people with the “rich and coherent
selves” they want. And, in part because therapists don’t engage in the
serious moral dialogue required to develop rich selves, the authors ask
whether “psychological sophistication has not been bought at the price of
moral impoverishment” (Bellah et al. 1985:139).
As early as 1968, Maslow took pains to distinguish self-actualization
from selfishness (Wallach and Wallach 1983). By 1970, he acknowledged
that some of his earlier work was overly individualistic. Nevertheless,
mirroring the experience of other therapists and corroborating the views
of critics of individualism, Doherty stated that he became aware of his
having been “unwittingly promoting a moral agenda of self-interest”
(Doherty 1995:26). He asserted:
I have seen too many parents “move on” from their children, too
many spouses discard a marriage when an attractive alternative
appeared, and too many individuals avoiding social responsibility
under the rubric of “it’s not my thing.” Widespread reevaluation of
the fruits of unfettered self-interest at both the psychosocial and
economic levels is under way in the mid-1990s.
(Doherty 1995:10)
Distancing himself from regressive critics of therapy’s emphasis on the
self, Doherty advocates a progressive alternative to traditional
individualism.
A growing concern for the welfare of others is thus joining therapy’s
traditional ideal of concern for the self. Good relational ends are
affirmed, ends pertaining to family, friends, community, work, society, or
humanity as a whole, as well as good environmental ends (e.g. ecological
concern as therapeutic goal or positively evaluated outcome).
Some relational therapy ideals pertain to the ability of clients to
interact with others effectively; the goodness of something larger than the
client (e.g. society) is emphasized in other ideals. Strupp combined both
emphases when he asserted that “the purpose of therapy is to strengthen
the patient’s adaptive capacities, to provide whatever assistance may be
necessary to enable the patient to lead a more satisfying life as a
responsible citizen in our culture” (Strupp 1980:397).
“Adaptation,” a therapy ideal pertaining to the individual’s
relationship with others, is both praised and condemned. If viewed as
conformity to a society that hampers human flourishing, adaptation is
condemned, as when military therapists in Vietnam eliminated soldiers’
moral qualms so they could kill again without reservation (Lifton 1976).
But Wallace (1986, 1991) argues that adaptation, as employed by Freud
and others, is a richer, more defensible concept. He defines it as a
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 211
“creative and productive engagement with reality (akin to Freud’s
Arbeiten und Leiben)—one optimally suitable for the deeply rooted needs,
desires, and aims of self, and cognizant of beloved and loving others and
human and nonhuman environments” (Wallace 1991:106).
Using less controversial terms, Jahoda (1958) and others have discussed
the ability of clients to interact and communicate with others, to love,
work, and play. These good ends pertain to social skills and
environmental mastery, to the ability of clients to maintain good
interpersonal relations.
Helping others is a more ambitious relational goal than developing
effective social skills. Allport contended that one criterion for mental
health is “a compassionate regard for all living creatures,” including “a
disposition to participate in common activities that will improve the
human lot” (Allport 1960:162). And Nicholas (1994) urged therapists to
openly prefer (when not clinically contraindicated) the good ends of
altruism, egalitarianism, and justice (cf. Michael 1977; Prilleltensky 1997).
Doherty (1995) argued that a concern for one’s community is a good
therapy outcome. Therapists, he suggested, validly introduce relational
considerations, like whether a particular action would hurt a client’s
family members. And, without claiming therapists alone can change a
society, he suggested that therapists can help clients rejoin, and take
seriously their responsibilities to, their communities.
Therapy stakeholders are thus increasingly affirming goals embracing
both the well-being of individual clients and larger relational concerns.
Feminist and multicultural therapists (Rodis and Strehorn 1997),
advocates of managed care (Austad and Berman 1991b), community
psychologists (Prilleltensky 1997), philosophers (Taylor 1992), those who
are hermeneutically-oriented (e.g. Richardson and Guignon 1988), those
articulating Jewish (Goodnick 1977) and Christian (Browning 1987)
understandings of ideal human functioning, and others affirm this.
Wanting to reject both self-indulgence and authoritarianism (Wallach and
Wallach 1991), both selfishness and a loss of self, both the individualistic
status quo and regressive authoritarianism (Doherty 1995), advocates
affirm a concern for self and others.
Those unconvinced on ethical grounds that a social element should be
added to therapy goals may need, on practical grounds, to introduce one:
those who pay for therapy increasingly require it. Managed care
advocates Austad and Berman assert, for example, that “concern for the
individual and the collective group” is needed (Austad and Berman 1991c:
viii, emphasis added).
The ideal balance between care of self and care of others is a matter of
considerable disagreement. Browning (1987) argues convincingly that
when Freud affirmed “love” (Fine 1990) as a therapy goal, he meant only
a “cautious reciprocity”: a person responds to the loving initiatives of
others but does not initiate them. And so a person “loves” only when
first loved, and only to the extent the person receives love. Actions
benefiting others but not oneself are viewed with great suspicion.
Doherty, by way of contrast, argues that “therapists since the time of
212 ETHICS AND VALUES IN PSYCHOTHERAPY
Freud have overemphasized individual self-interest, giving short shrift to
family and community responsibilities” (Doherty 1995:7). The balance
considered ideal is likely to vary across schools of therapy, across
therapists, and across clients of the same therapist, in accord with each
particular client’s needs and situations.
Some therapists, especially humanistic psychologists, argue that society
will benefit most when clients choose their own goals and focus on
themselves. They assert that “the general good is best served by
individuals’ focusing on their own needs and actualization” (Wallach and
Wallach 1983: 164; see Parloff 1967). That assertion rests on the
metaphysical assumption that, in our harmonious universe, focusing on
one’s self will benefit others (Browning 1987). So strong and extensive are
their metaphysical convictions about the goodness of persons and the
harmonious order of the cosmos, humanistic psychologists are, in
Browning’s words, “at this point on equal logical footing” (ibid.: 122)
with advocates of religious perspectives.
Spiritual and religious traditions posit concepts of goodness that
clients, therapists, and other stakeholders employ as therapy goals or use
to evaluate outcome. Jafari, for example, argued that Western therapy is
inappropriate for Islamic clients because so many of its assumptions
conflict with Islamic understandings of reality and Islamic ethics.
“According to the Qur’an,” he notes, “a life without faith is a state of
spiritual non-being in which one loses touch with his/her true self (49:
19)” (Jafari 1993:335). Islam affirms, he argues, the goodness of righteous
benevolence rather than (Western) self-fulfillment, the goodness of a
holistic (i.e. individual and collective; mental, physical, and spiritual)
rather than a materialistic outlook, the goodness of bounded rather than
unbounded freedom, and the goodness of repentance rather than
rationalizing guilt away. Tyler and Suan (1990) found that Native
Americans were more likely to view unconventional spiritual experiences
(e.g. having visions) as signs of good mental health than were Caucasian
students. Schimmel (1992) explored differences and commonalities
among Jewish, Christian, and classical understandings of human nature
in relation to the views of contemporary psychotherapists. Some
Christian concepts of goodness mirror those of non-religious therapists;
others clearly diverge. Calvinists committed to the Shorter Catechism of
the Westminster Confession, for example, assert that our “chief end is to
glorify God and to enjoy Him forever” (Westminster Divines 1745:369).
Browning (1987) and Jones and Butman (1991) explored the ways in
which the ethical component of therapy goals among various therapeutic
approaches are like, and unlike, Christian ethical traditions.
Virtues
To evaluate therapy outcome and to establish goals, some therapy
stakeholders employ concepts of virtue. Maslow, for instance, asserted
that the person who has completed a successful course of therapy is a
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 213
“better person” (Marlow 1961:8). And Strupp and Hadley suggested that
“mentally healthy” persons have “a sound personality structure
characterized by growth, development, self-actualization, integration,
autonomy, environmental mastery, ability to cope with stress, reality
orientation, [and] adaptation” (Strupp and Hadley 1977:190). That is, they
have those desirable and stable characteristics; they exhibit the virtue of
mental health.
Other therapy stakeholders emphasize or champion other virtues.
Although virtues were not the central focus of Freud’s ethical thinking
(Wallace 1986), several virtues are evident in his thinking: honesty (Rieff
1979; Wallace 1986), autonomy (Szasz 1965; Wallace 1986), integration
and balance (Michels 1987, 1991), and the genital character (Gewirth
1956). Humanistic psychologists offered a rich array of virtues. In his
discussion of the good life, for example, Rogers described the
characteristics of a person in the process of becoming fully functioning:
“an increasing openness to experience,” “increasingly existential living,”
and “an increasing trust in one’s organism” (Rogers 1961:187, 188, 189).
Other humanistic virtues include self-actualization, spontaneity,
creativity, authenticity, expressing one’s emotions, present-centeredness
(Naranjo 1970), and so forth. Authenticity is a virtue emphasized by
others as well, but understood in different ways. Guignon, for example,
argued that authenticity “can be nothing other than a fuller and richer
form of participation in the public context” (Guignon 1993:228; see Taylor
1992). Guignon identified the following “character ideals” in Heidegger’s
ideal of authenticity:
Authentic self-focusing is said to require such traits as resoluteness,
steadiness, courage, and, above all, clear-sightedness about one’s
own life as a finite, thrown projection. It calls for integrity and a
lucid openness about what is relevant to one’s actions. The
authentic stance toward life makes us face up to the fact that to the
extent that we are building our own lives in all we do, we are
“answerable” for the choices we make.
(Guignon 1993:232)
Nicholas (1994) argued that therapy ideally produces people who are
altruistic, egalitarian, honest, just, and responsible. Doherty (1995) argued
for the virtues of self-awareness, interpersonal sensitivity, moral
awareness, moral courage, moral responsibility, integrity, integration,
and balance. Some traditionalists no doubt view submissiveness in
women as a virtue. By way of contrast, Seiden noted that feminist
therapists respond with a “hearty laugh” to “the idea that a healthy
woman is characterized by passivity” (Seiden 1976:1117). Feminist
therapists, of course, affirm virtues other than submissiveness and
passivity.
214 ETHICS AND VALUES IN PSYCHOTHERAPY
Wolfe (1978) argues that the kind of person who emerges from
successful therapy has an internal “locus of moral authority.” Doherty
(1995) argues for “ethical “ethical self-empowerment” (Doherty 1995:54,
emphasis added). And Freud clearly regarded as healthier those persons
whose ethical principles are independent of religious foundations
(Wallace 1986). By way of contrast, Geller argued that “far from finding
direction from within, we can only find it from without” (Geller 1982:61).
And others affirming spiritual and religious traditions (Browning 1987;
Goodnick 1977; Jafari 1993; Jones and Butman 1991) would concur with
some form of Geller’s opinion: ethical sources outside the self may be
legitimate. Therapy stakeholders may thus affirm virtues like
centeredness, peace, faith, hope, love, holiness, sanctification,
righteousness, glorifying God, and so forth. By way of contrast, Engler
(1986) and others who draw upon Eastern sources challenge the notion of
the self found both in Western religious traditions and in Western nonreligious traditions, arguing instead for the goal of “no-self.” Some who
affirm spiritual virtues see them to be harmonious with mental health
(therapists’ ideals are affirmed, spiritual ideals may or may not be
reached by mentally healthy persons); others see spiritual virtues to be an
integral part of mental health (full mental health requires those spiritual
virtues).
When discussing therapy ideals, therapy stakeholders face a challenge:
whether using the language of virtues, principles, or goodness, crucial
terms often have multiple meanings. The self, happiness, selfexploration, maturity, identity, growth, identity, self-reflection, the
individual, self-fulfillment, love, and mental health carry different
meanings for different stakeholders. For example, if we assert that the
“capacity for honest self-reflection” is a good therapy outcome, we may
do so for a variety of reasons. As Taylor (1989) notes, we may value selfreflection in order to see the forms underlying the appearances of life
(Plato), to see the order of things (Aristotle), to see God (Augustine), to
gain self-mastery and control (Descartes and Locke), to discover oneself
(Montaigne and Herder), or to make a personal commitment.
“Self-actualization” is also variously interpreted. The sticking point
concerns what is actualized. As Jahoda (1958) noted, “self-destruction and
crime, from petty thievery to genocide, are among the unique
potentialities of the human species” (Jahoda 1958:31; cf. Phillips, 1987, on
behavior that can be justified as being “authentic”). Those potentials are
not, of course, the potentials humanistic psychologists contend the “selfactualized person” actualizes. Browning (1987) notes that selfactualization theorists, in fact, make judgments about what is good, then
focus on that goodness as what self-actualization produces in people. As
Franck notes, those who use “self-actualization” or “self-realization”
actually argue that “certain aspects of the self and not the entire self…
ought to be actualized, namely, only those aspects of the self…considered
by these psychologists to be ‘good’ ” (Franck 1977:9).
And so the multiple terms that therapy stakeholders use to describe
therapy goals and outcome—whether principles, concepts of goodness,
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 215
or virtues—have multiple meanings. One reason for those multiple
meanings is the ethical theory underlying those ideals.
Therapy ideals and ethical theory
Differing ethical theories and differing philosophical assumptions
produce diverse therapy ideals. And even when apparent consensus
about therapy goals and evaluations of outcome exists, the reasons for
affirming them may diverge. As Taylor notes, beneath the apparent
consensus of those who affirm the same values we often find “various
richer pictures of human nature and our predicament” (Taylor 1989:12).
And so there is disagreement among therapy stakeholders of good
will. They disagree, for example, about whether therapy ideals find their
proper source within an individual, outside an individual (e.g. from
science, community, or some spiritual entity), or from some combination
of both (e.g. in the dialogue between therapist and client). And, because of
contrasting metaphysical/ethical views, they disagree about what it
means to be “properly human” (Cushman 1995:282; see Engelhardt 1978;
Parloff 1967). For example, Patterson’s strongly held view is that selfactualization “is a goal that is not chosen by the therapist or the client,
nor is it simply a religious or philosophical goal. It is derived from the
nature of the human beings” (Patterson 1989:171). As noted above,
however, only some aspects of the self are actualized and only some
considered good or ideal (Franck 1977), that is to say those aspects
concordant with one’s metaphysical and ethical convictions. Furthermore,
the “nature” of human beings on which that therapy goal is based is
disputed philosophically. Freud held different assumptions about human
nature, and so established different therapy goals. Lear argued that
because Freud believed that “love is a basic force in nature”, he thought
love a proper therapy goal (Lear 1990:221). In contrast to both humanistic
psychologists and Freudians, Heidegger denied that a human nature
exists. Rather, he held that “we are what we make of ourselves in the
course of living out our active lives”; human beings are “self-constituting
beings” (Guignon 1993:223).
Those wishing to understand the ethical character of therapy goals and
outcome, and to arrive at the best possible goals and outcome, thus face
the task of clarifying and justifying the ethical theory to which therapy
ideals are tied. This will require choice, retrieval, or both. MacIntyre
(1984) argues that we must choose between a new form of classical
Aristotelian virtue theory and the liberal individualism for which
Nietzsche is the most clearsighted proponent. By way of contrast, Taylor
(1992) argues that we need to retrieve and articulate the ethical theories
upon which our ideals are based, acknowledging the legitimacy of each
(as appropriate) and drawing upon them as sources of ethical content and
motivation. Both MacIntyre and Taylor agree, however, that the reality of
multiple ethical ideals must be addressed.
216 ETHICS AND VALUES IN PSYCHOTHERAPY
Addressing multiple therapy ideals
Therapists, clients, and other therapy stakeholders face a wide range of
therapy goals and criteria for evaluating outcome, each tied to various
ethical ideals (principles, concepts of goodness, and/or virtues). Those
ideals are tied in turn to ethical theories and fundamental philosophical
understandings of human beings. How then do therapists, clients, and
other therapy stakeholders choose goals, evaluate outcome, and
determine which goals and outcome criterion are valid? If faced with
more than one valid ideal, what should be done? If conflicts arise, how
should they be addressed? To address those questions, many strategies
have been proposed. In this section, I will discuss nine overlapping, often
complementary strategies.
Because scientific methods have answered other psychological
questions so successfully, some turn to science to determine which ideals
are best, or should be selected. But as discussed in Chapter 6, science can
evaluate whether a particular technique will achieve a particular result.
But it cannot tell us whether that end is good, right, obligatory, or
virtuous. Science can be helpful, however, in establishing goals at a
middle level of abstraction. For example, if all agree that decreased
depression is a good therapeutic end, empirical studies can tell us
whether the middle-level goal of combating depressogenic cognitions
contributes to the ultimate goal of decreased depression. But it cannot
ethically evaluate that ultimate goal. Science can also provide some
knowledge about human nature. It can tell us, for instance, about various
human capacities. But it cannot tell us which of those capacities is ideal.
Carefully evaluating and choosing ideals is a second proposed
approach to the diversity of ethical ideals. This philosophicalpsychological task entails asking which ideals are good, right, and/or
virtuous, and the often-more-challenging question of which are best. Some
proposed goals may be rejected and certain outcomes evaluated as
failures (e.g. the client whose depression worsens or who becomes
“selfish”—B.E.Wolfe 1978). But a third category should be added:
following Worthington’s (1988) suggestion, therapy ideals can be divided
into one of three categories. Ideals are located in zones of rejection, zones
of toleration, and zones of affirmation. Some ideals are rejected (e.g.
Bob’s request that Dr Peterson tell him what to do), some tolerated (e.g.
the agnostic Dr Peterson’s toleration of Bob’s conservative Christian
ideals), and some affirmed as optimal. Therapists who aspire to be
accepting and as value-free as possible require a large zone of toleration
to work with the widest possible range of clients. But the influence on
clients of the ideals therapists affirm and the intrinsic ethical excellence of
those ideals (or lack thereof) mean therapy stakeholders also need to
think clearly and well about the goals and outcomes they think best.
Therapy ideals can be evaluated and chosen on three levels: ideals for
humankind in general, ideals for therapy in particular, and ideals for a
given client at a particular point in time. An ideal appropriate for therapy
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 217
in general (e.g. assertiveness) may not be appropriate for a particular
client (e.g. a client whose failure to be sensitive to partners and inability
to listen or compromise with others produce unsuccessful and
emotionally distressing relationships). And goals that may be appropriate
in general (e.g. global peace and justice) may not be an appropriate focus
for a particular individual (e.g. a mentally ill client overwhelmed with
stressors and obligations).
Evaluating therapy ideals is difficult for those whose training is solely
in the sciences or solely in philosophy. Because I am convinced that the
best evaluations draw upon both, evaluating therapy ideals is especially
difficult for those prejudiced against either philosophy or psychology.
Evaluating therapy ideals is also made more difficult by the covert
character of many of therapy’s ethical ideals. To make such evaluations
easier, acts of retrieval are required, so we can recover the rich ethical
character of therapy goals and practices, recapture the multi-faceted,
multi-layered, and conceptually complex ethical meanings of terms like
authenticity, autonomy, effectiveness, the general welfare, mental health,
and love and work, and begin “making more palpable to {a culture’s}
participants what the ethic they subscribe to really involves” (Taylor 1992:
72). An especially important role will be played by therapy stakeholders
who exhibit ethical articulacy (Taylor 1989, 1992), who speak and write
lucidly and eloquently about therapy’s ethical ideals.
A third proposal to the problem of multiple therapy ideals is to
combine proposed ideals. Taylor, for instance, rejects the positions of
those who contrast social concern with authenticity and self-fulfillment
(which they assume produce selfishness and reinforce excessive
individualism). He asserts that authenticity requires social concern, and
rejects as “deviant and trivialized” (Taylor 1992:55) those modes of
authenticity that produce narcissism and self-centeredness. Other goals
also combine ideals. For instance, we can imagine a goal for Bob’s
therapy that combines his aspirations and those of Dr Peterson:
developing greater intra-psychic insight and clarity about his marriage.
As a final example, Doherty folds self-interest as a therapy goal into a
broader, more inclusive ethic of the common good, in which self-interest
is “embraced and transcended” (Doherty 1995:101).
Others who affirm more than one distinguishable therapy ideal balance
ideals in some way. Aristotle, for example, argued for the “Golden
Mean,” a goal avoiding the extremes of either too little or too much of the
elements of the good life (Taylor 1989). Taylor argues that a particular
good end “needs to be part of a ‘package,’ to be sought within a life
which is also aimed at other goods” (ibid.: 511). In applying this to
psychology, Prilleltensky argued that psychologists should employ
“complementary” values “in concert” rather than in isolation
(Prilleltensky 1997:521). And Wallace asserts that balance was Freud’s
“central metaphor” (Wallace 1986:110).
Striking a balance between concern for the individual and concern for
some larger social grouping is evident in the reflections on mental health
by Austad and Berman (1991c), Browning (1987), Doherty (1995), Freud
218 ETHICS AND VALUES IN PSYCHOTHERAPY
(Wallach and Wallach 1983; Wallace 1986), Mahoney (1991), Odell and
Stewart (1993), Prilleltensky (1997), Rodis and Strehorn (1997), Veatch
(1978), and others. Balancing autonomy and other ideals has also been
advocated (Bellah et al. 1983; Callahan 1984; Freud, as interpreted by
Homans 1979; Prilleltensky 1997; and Richardson 1989). And Buhler
(1962) and others have maintained that health should be appropriately
balanced with other ideals.
Doherty optimistically asserted that ideals can be balanced without
compromising any. He argued, for example, that personal authenticity
“must not be put in competition with morality” and that “there is no
inherent contradiction between self-fulfillment and moral responsibility
to others” (Doherty 1995:67, 78). This is certainly true at times. But many
people face choices among ideals. One’s own fulfillment, for instance,
may conflict with responsibilities to others. As Taylor noted, affirming
multiple goods can result in “a cruel dilemma, in which the demands of
fulfilment run against these other goods—one which thousands of
divorcing or near-divorcing couples are living through in our time, for
instance” (Taylor 1989: 511). And Veatch notes that physicians sometimes
face ethical dilemmas in which one course of action “will produce the most
good in total, but another course will most benefit the client” (Veatch
1978:173). Therapists also face dilemmas. As Odell and Stewart (1993)
point out, situations arise in which a particular change benefits one
family member but harms another.
When faced with dilemmas among competing ethical ideals, and
balance is not possible, ranking them is an alternative strategy (Taylor
1989). Stakeholders determine which ideals are most important and
which are not. Psychoanalytic theories, for instance, give priority to the
individual over the collective, argues Michels (1987), a tendency which
Wallach and Wallach (1983) find even more pronounced in neo-Freudian
and humanistic therapeutic approaches. Mental health also has to be
weighed against other ideals, such as civil liberties, justice, peace
(Michels 1976), individual rights (Callahan 1988), alternative paths to
happiness, and “such very different life goals as service to other persons,
to the state, or to God; or the achievement of some ideal such as
advancing knowledge, pursuing honor, or creating something of lasting
or absolute value” (Gettner 1978:1060). Such ranking occurs for individual
clients (some clients may need to take better care of themselves; others to
become less self-absorbed), as well as in general. And one therapist may
consider Bob’s happiness to be of paramount importance in his therapy,
but another the well-being of his children.
Devoting particular attention to the most important or “superordinate”
(London 1986:9) ethical ideal is a sixth approach to addressing multiple
ideals related to therapy goals and outcome. J.Michael, for instance,
argued that “cultural survival” is the “primary value” held by radical
behaviorists, with other values being relegated to “secondary status”
(Michael 1977:295). Taylor refers to individuals’ most important ethical
ideals as “hypergoods,” which he defines as “goods which not only are
incomparably more important than others but provide the standpoint
ETHICAL DIMENSIONS OF THE GOALS AND OUTCOME OF THERAPY 219
from which these must be weighed, judged, decided about” (Taylor 1989:
63). Hypergoods are critically significant from both an ethical and a
psychological perspective. Taylor argues that:
the one highest good has a special place. It is the orientation to this
which comes closest to defining my identity, and therefore my
direction to this good is of unique importance to me. Whereas I
naturally want to be well placed in relation to all and any of the
goods I recognize and to be moving towards rather than away from
them, my direction in relation to this good has a crucial importance.
…if I am strongly committed to a highest good in this sense I find
the corresponding yes/no question utterly decisive for what I am as
a person.
(Taylor 1989:63)
“Unconstrained freedom,” he suggests, is “the most pervasive of all
modern goods” (ibid.: 489). That and mental health, variously defined,
are the hypergoods most relevant to psychotherapy.
When health functions as hypergood, it becomes the human value
(Goldstein 1959; Monopolis et al. 1977), from which “all other values
experienced under special conditions become comprehensible”
(Goldstein 1959: 188). And so, all therapies “share a value system that
accords primacy to individual self-fulfillment” (Frank 1978:6). And
Wallach and Wallach document how neo-Freudians let “psychological
values preempt all others” (Wallach and Wallach 1983:117). Selfactualization, argues Patterson, “is, or should be, the goal of society and
of all its institutions” (Patterson 1989: 171). Those assertions vividly
exemplify American individualism and expressivism, whose adherents,
Taylor (1989) argues, hold self-realization in such high regard that no
goods can trump it.
But not all agree that mental health should be a hypergood. Hartmann
(1960) argued that not even mental health professionals, apart from their
professional activities, consider mental health to be their highest value
(see also Buhler 1962). Indeed, notes Michels, some contend that ethical
ideals like social justice and civil liberties “are of superordinate value.”
And so, “when they conflict with therapy, the therapy must retreat”
(Michels 1976: 382).
Distinguishing between two forms of hypergoods may, I think, be
helpful. Rescher drew a distinction between monistic “summum bonum
theories that seek to found a monolithic, inverted-pyramid structure of
value upon one single, solitary end value to which all others are somehow
means,” and multivalent theories that are “polychromatic and envisage a
plurality of distinct end values which, even if some are ‘higher’ than
others, are at any rate subordinated to them in a mean—ends hierarchy”
(Rescher 1969:54). In the latter case, mental health can be regarded as a
penultimate goal for those clients whose hypergood is not mental health.
220 ETHICS AND VALUES IN PSYCHOTHERAPY
Achieving mental health enables them to reach the ideal they consider
their highest. Therapists working with such clients will ideally employ a
sufficiently flexible definition of “mental health” to facilitate reaching the
goals therapy stakeholders have set.
The challenge posed by this chapter can thus be recast as one of
adjudicating among the ethical ideals, and the hypergoods, of therapy’s
various stakeholders. When the ideals of all therapy stakeholders are
considered, the final three approaches to multiple therapy ideals come
into view, approaches to be addressed in more detail in the remaining
chapters of the book.
Ongoing, extensive psychological—ethical discourse among all therapy
stakeholders is the seventh approach to the problem of multiple therapy
ideals. That, I trust, is a function this book will facilitate.
Revising the therapeutic contract to address the ethical character of therapy
and developing an improved public philosophy that addresses the ethical
character of therapy goals and outcomes—the eighth and ninth
approaches—move the discussion from the level of the solitary decision
maker to the level of communities and societies. Those approaches to the
thorny issues of the ethical character of therapy goals and outcome will
be addressed in Chapter 10.
Part V
Implications
10
Rethinking psychotherapy’s location in a
society
Public philosophy and social and therapeutic
contracts
Because psychotherapy is an inextricably ethical endeavor—not simply
the technical application of scientific findings, not simply a medical
treatment to reduce psychological distress, and not simply a journey of
personal growth—we need to reexamine those understandings of therapy
that are based on the assumption that therapy is either value-free or
inconsequentially value-laden. And so, in these final three chapters, I will
explore some implications of understanding psychotherapy to be deeply
and ineradicably ethical.
Suppose that Anna, a 38-year-old expectant woman, is depressed. Her
morning sickness is not going away. And her husband seems
preoccupied with his work, unconcerned about her, and apathetic about
becoming a father to a new child. She worries about what life will be like
when the baby comes. And she wonders whether she should follow the
advice of her neighbor: “get rid of it, you don’t need any more children.”
She sleeps poorly. Her appetite is diminished. And she does not feel
supported by the male religious leader supposedly concerned about her
well-being. (She has long belonged to a religious group whose total
membership is less than one percent of the population in her society.)
During a visit, her mother asks how she is doing. Anna weeps.
If the processes, goals, and outcomes of any psychotherapy Anna
receives embody answers to ethical questions to a greater extent than
generally believed, and if the clinical, scientific, and business contexts of
therapy also carry with them certain ethical answers, then old answers to
key questions about psychotherapy no longer satisfy. And so therapy
stakeholders have the opportunity, and perhaps the obligation, to rethink
therapy in light of its ethical character. In this chapter, I will address the
role of therapy in societies, focusing on articulating and revising current
implicit public philosophies and contracts (therapeutic and social)
concerning therapy. This chapter primarily involves social and cultural
ethics. Chapter 11, in which I will reexamine selected dimensions of
professional ethics, primarily involves professional and clinical ethics. I
will argue, however, that the topics addressed in both chapters are tied in
important ways to fundamental questions of theoretical ethics, because
answers to the issues discussed in both chapters grow out of the deepest
ethical convictions and motivations of human beings. But those moral
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 223
sources are too often occluded. And so, in Chapter 12, I will address how
therapy stakeholders can make better ethical choices, choices that may
improve the ethical character of therapy.
Although my focus in these chapters will be the implications of
therapy’s ethical character, some of the issues addressed represent ethical
dimensions of psychotherapy which I have not yet addressed. And so
these chapters will add to the portrait of the ethical character of
psychotherapy which I have been developing throughout the book.
For better or worse, I will not provide anything approaching definitive
or certain answers. But I hope to demonstrate that we can address in
fruitful ways the vitally important questions of the ethical character of
psychotherapy, doing so without resort to the “easy” solutions of
relativism and absolutism.
A public philosophy for psychotherapy
By a public philosophy for psychotherapy, I mean ideas about the ideal
role of therapy in society, about therapy’s purpose and participants, and
about its relationship with other spheres of society. Or, to paraphrase
Browning, public philosophy involves discourse about, giving an account
of, or providing reasons for, “the main focus of the {psychotherapy}
profession and…the appropriate relation of [psychotherapy] to other
regions of social life, for example, law, politics, ethics, and religion”
(Browning 1991a: 18).1
In discussing a public philosophy relevant to Anna in the above
example, I thus want to address how her society views psychotherapy: is
it supported? does her government raise taxes to pay for it? does part of
her (and/or her husband’s) compensation package include some form of
health insurance that will pay for therapy? if some party other than Anna
and her family pays for it, to what extent and under what circumstances?
is long-term therapy supported? with what images do those who shape
Anna’s society portray therapy (e.g. in the media, in written works, in
religious exhortations, and so forth)? is going to a therapist shameful,
acceptable, or “cool”? and, what reasons (ethical and otherwise) are given
for those answers? finally, when an explicit public philosophy is absent,
which answers are implicit in societal images and stories and in
institutional structures and arrangements?
Answers to those questions are, of course, hotly disputed. They vary
across cultures, across subcultures within pluralistic societies, and within
subcultures. If Anna lives in Saudi Arabia, that nation’s public
philosophy regarding psychotherapy would differ from the public
philosophy if she lived in Japan, Finland, Angola, or the US.
Psychotherapy occupies a different location in each society.
We understand the role of therapy in a society when we get an
overview of the society and see therapy’s place within it—its actual place
and its location relative to citizens’ aspirations for it. My topographical
metaphor, “the location of psychotherapy in a society,” refers to the
224 ETHICS AND VALUES IN PSYCHOTHERAPY
breadth of public philosophy and to public philosophy’s role in
describing the relationship between therapy and a society as a whole. A
public philosophy for therapy addresses the relationship of
psychotherapy to other professional activities, to other ways people
change, to the destination(s) (good or ideal ends) toward which society
wants to move, and to other dimensions of a society. As Kiesler and
Morton argue, “a top-down analysis of resource allocation is necessary for
responsible public policy in health and mental health care” (Kiesler and
Morton 1988:993). And Clark (1993) argues that socially responsible
psychologists can function in either the micro-ethical sphere (in their
relationship with clients) or the macro-ethical sphere (the realm of social
policy). This movement from thinking about individual therapy clients to
thinking about the broader societal level (analogous to moving from an
individual view of psychopathology to a family-systems perspective) is
important. A society may (and usually does) have multiple needs but
may lack the resources to meet all those needs. It would be unwise, for
instance, to devote large sums of governmental funding to long-term
therapy for Anna’s sub-clinical depression in a society in which resources
are inadequate to meet basic nutritional and educational needs. A topdown analysis permits therapy stakeholders to understand that macroethical sphere and delineate psychotherapy’s ideal location within a
society.
By “public” philosophy, I mean a discussion about the public rather
than private role of therapy and about the public (society-wide)
implications of therapy. In the kind of public discussion (Bellah 1986)
that produces an optimal public philosophy, no one’s views are excluded
and all stakeholders give public reasons for their views, not relying solely
on their disputed basic ethical assumptions. The classic liberal in a
pervasively religious society is given a voice, as is the religious minority
in a pervasively secular state. Whenever full ethical agreement is not
possible (and in most societies full agreements of any depth about the
ethical character of therapy will be rare), a “best possible” working
agreement is sought.
A public philosophy concerning psychotherapy is important for
several reasons. All societies have such a philosophy—at least implicitly
(M.A.Hall 1997). Articulating such philosophies facilitates their
evaluation and, if necessary, their revision.
Second, although public philosophies are articulated abstractly, they
have profoundly practical implications because they are translated into
public policies (through the ugly, powerful, inefficient, tension-filled
mechanisms of politics). Such policies deeply affect psychotherapists and
their clients, for good or ill. And so a public philosophy can either
contribute to good mental health in a society or its opposite. As Frank
and VandenBos stated, “psychologists must be involved in policy issues
so as to ensure the utilization of psychological knowledge and attention
to psychological and behavioral health needs” (Frank and VandenBos
1994:851). Of particular importance are the battles over funding for
therapy, and control of that funding. Hall observes that decisions about
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 225
funding are made at several levels. At the broadest level, he notes, “at the
macro or global level, society must decide, whether purposefully or by
default, how much of its resources to devote to the medical enterprise”
(M.A.Hall 1997:6). A society that develops an articulate, explicit public
philosophy about psychotherapy psychotherapy’s location within it will
be more likely to develop a satisfactory consensus about such policy
issues than one in which conflicting views are implicit.
A public philosophy for psychotherapy is also important in order to
protect the autonomy and professional judgment of the psychotherapist.
The psychotherapy profession needs, in Browning’s words, “to protect
itself and its treatments from exploitation by fashionable trends or
politically ambitious powers that might like to use the increasing
technical skills of contemporary psychiatry” (Browning 1991a:20). And,
one might add, to protect itself from economic powers that want to
reduce expenditures for therapy, thereby preventing clients from
reaching good therapy goals.
Other ethical implications of public philosophies for therapy are also
important. A public philosophy for therapy that recognizes that therapy
is deeply and inextricably ethical in character will be different from (and
more complex than) a philosophy that assumes therapy is value-free.
Because the ethical convictions held by various therapists and underlying
different forms of therapy differ (at times dramatically), the way in which
a public philosophy handles ethical differences is vitally important. If
Anna is a Muslim in a predominantly secular country, its public
philosophy addresses whether therapists try to conform her to a secularist
mold or treat her religion more respectfully. Likewise if she is Unitarian
in a society governed by fundamentalists. A public philosophy must
wrestle with ethical diversity among therapists and clients and across the
society as a whole. All stakeholders may applaud the diminution of
Anna’s depression. But they may disagree about other changes produced
by therapy—changes in her views of abortion, the proper relation of
husband and wife, the role of religion in her life, and so forth.
In the remainder of this chapter, I address the role of therapy in a
society. I will emphasize therapy’s ethical dimensions, the process of
making decisions about the role of therapy in society, and the process of
crafting a public philosophy in the presence of ample, deep-seated ethical
diversity. Finally, I will address therapeutic and social contracts about
therapy.
Ethical dimensions of the role of therapy in a society
The “traditional” role of modern psychotherapy is, of course, of very
recent origin, arising in Europe and the US from a variety of sources—
religious, medical, philosophical, and educational (Abbott 1988;
E.M.Caplan (forthcoming); Freedheim 1992). Psychotherapists at first
borrowed the social location (and legitimacy in society) of their
professions. Freud, for instance, originally considered psychoanalysis a
226 ETHICS AND VALUES IN PSYCHOTHERAPY
medical procedure (Strupp 1986). Psychotherapy appealed to large
numbers of people, in part “because of its association with science,
medicine, technology, and the romantic features of psychoanalysis”
(Browning 1991b: 6). Therapy thus appealed to the ethical ideals behind
both of the modern understandings of the self outlined by Taylor (1989).
Eventually, psychotherapists, professional associations, and various
governmental entities collaborated to develop specialized certification
and licensing procedures. Psychotherapists became professionals (if not
already considered professionals) (Association of State and Provincial
Psychology Boards 1996; Gorlin 1994; Hatch 1988b; Hogan 1979; Young
1987). Recognition of psychotherapists as professionals was vitally
important. But, as London notes:
our society only sanctions the practice of psychotherapy and the
existence of therapeutic guilds because of a tacit assumption that
the moral order to which therapists address their skills is one that
ultimately benefits the social order through its treatment of the
needs of individuals.
(London 1986: xvi; see Meara et al. 1996)
That is, society sanctions psychotherapy because it benefits society.
The ethical assumptions of traditional public philosophy regarding
psychotherapy were thus straightforward. Mental illness is bad.
Eliminating it and producing mental health are good, both for the
individuals involved and for society as a whole. Professionals effectively
treat mental illness and produce mental health. And, as professionals,
they abide by a code of ethics and commit themselves to the well-being of
their clients. Therapists’ efforts are therefore supported and they receive
the public recognition and autonomy granted other professionals.
But the current picture is more complicated. Psychotherapy’s social
location changed when third-party payers began paying for therapy. A
revised social contract entailed a (usually implicitly) revised public
philosophy. Many societies are now renegotiating this contract. As the
psychiatrist C.K.Aldrich put it:
As long as Jones paid me for his psychotherapy or friendship, or
however he wanted to use the time I sold him, it was none of
Smith’s business. But when Smith’s taxes or insurance premiums
began to contribute to my fee, Smith’s interest in what I was doing
with Jones increased. In other words, Smith now expects me to be
accountable—and in terms that he can understand.
(Aldrich 1975:509)
Of particular importance is the fact that the traditional public philosophy
was based, in part, on the alleged ethical neutrality of psychotherapy. As
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 227
Guignon points out, “scientific endeavor from the outset has aimed at
being value-free and objective” (Guignon 1993:217). This scientific
emphasis was combined with Freud’s emphasis on “neutrality,” Carl
Rogers’ emphasis on the “non-directive” nature of his therapeutic
approach, and other factors to produce a deeply enshrined myth: valuefree therapy.
As Michels (1991) points out, however, this claim of therapeutic
neutrality “concealed” the ethical functions of therapists. I want now to
address those ethical functions, all relevant to a public philosophy for
psychotherapy. After discussing societal policies related to
psychotherapy, I will briefly discuss some ethical ideals related to
therapy, the ethical idea of the professional within a society, therapy in
relationship to other spheres of society, and the role of culture.
Policies translate public philosophies concerning psychotherapy into
action. As Birch and Rasmussen point out, goodness “is sometimes
promoted by social arrangements and sometimes obstructed by them.
But social arrangements are never neutral” (Birch and Rasmussen 1989:
91). Policies, created by governmental entities, corporations, non-profit
entities, and independent business people and professionals, may be
formal or informal, and explicit or implicit. Policy involves balancing
what is considered ideal with perceptions of reality (which can
sometimes be influenced by pertinent psychological research; see
Desjarlais et al. 1995; Kiesler et al. 1991; Lorion et al. 1996; Rochefort 1989;
Speer and Newman 1996). Policies relevant to therapy address which
persons are licensed by governmental agencies to function independently
as psychotherapists, which persons are authorized to receive payment
from governments, corporations, or insurance companies, and which
clients are eligible to receive reimbursed therapy (and how much of it).
Policy decisions can be evaluated ethically. Hall, for instance, notes that
societies “have always rationed health care resources on a massive scale,
but according to irrational and unjust principles” (M.A.Hall 1997:5). If
policies in Anna’s society do not permit her to obtain therapy but do
permit a wealthier male neighbor to do so, de facto rationing exists,
rationing that that is prima facie unjust.
The task which policymakers face is made more difficult when the
reality of therapist-influence on client values and psychotherapy’s
conflicting ethical ideals is recognized. When faced with practical
decisions, about therapy with Anna or any other client, competing ethical
ideals must be balanced.
One of the most challenging ethical issues pertaining to a public
philosophy for therapy is whether, or under what circumstances,
psychotherapy benefits society. That psychotherapy sometimes benefits a
society as well as individual clients is not in dispute. But, as discussed in
Chapter 7, some think the financial cost of unlimited therapy harms
society. And, as discussed in Chapter 9, some think therapy can harm
society because therapists convert clients to an ideology of individualism,
selfishness, and political passivity. At times, we must choose between the
228 ETHICS AND VALUES IN PSYCHOTHERAPY
well-being of individual therapy clients and the well-being of a society as
a whole. Deciding which takes precedence is decidedly different at the
societal level than at the level of a therapist and a client privately
discussing therapy goals. Societies also regularly choose some balance
between individual and societal well-being in their policies regarding
therapy.
As discussed above, a society supports psychotherapy because it
believes the pursuit of the well-being of individual clients benefits the
society (London 1986; Veatch 1978). But there is a widespread (if
disputed) perception that therapists are more concerned about individual
well-being than the general welfare. And, indeed, therapists in the
empirical investigation of Fowers, Tredinnick, and Applegate (1997)
endorsed individualistic responses significantly more frequently than
responses affirming social embeddedness and responsibility. This
confirms an extensive literature arguing that, whatever their intentions,
the de facto ethical influence of many therapists on clients is
individualistic and therefore problematic (Cushman 1995; Doherty 1995;
Lasch 1978; MacIntyre 1984; Sampson 1988; Wallach and Wallach 1983,
1990).
Albee and Ryan-Finn (1994) make a different critique of the current
public philosophy concerning mental health. They argue that societies
should devote far more resources to the prevention of psychological
problems rather than waiting until people are impaired and in distress
and then spending much more money.
In response to these criticisms (and, in some societies, to the reality of
changing reimbursement systems), therapists increasingly emphasize
societal as well as individual well-being. In a presidential column for the
American Psychological Association’s Division of Family Psychology,
Silverstein argued that “if psychology is to become recognized by the
public and by managed care as a major player in the mental health
marketplace, we must be seen as proficient in addressing the nation’s
social concerns” (Silverstein 1997:5).
Many therapists, philosophers, and cultural commentators now argue
for a balance of individual and societal well-being (Callahan 1990;
Cushman 1995; Doherty 1995; Gelpi 1989; Sampson 1993; Taylor 1992;
Wallach and Wallach 1990). Bellah, Madsen, Sullivan, Swidler, and
Tipton argue that “the goal must be nothing less than a shift from radical
individualism to a notion of citizenship based on a more complex
understanding of individual and social happiness” (Bellah et al. 1991:
107). And, in an assertion that underscores the importance of the
professional nature of psychotherapy (to be discussed later in this and the
following chapter), Meara, Schmidt, and Day argue that “communities
grant professional autonomy to those professions that competently
perform needed services and take seriously (above their own selfinterests) the welfare of the individuals with whom they work and the
good of the community at large” (Meara et al. 1996:69).
Disagreement about ethical ideals is at the heart of the debate about a
public philosophy for psychotherapy. A variety of ideals is championed.
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 229
Therapists stress mental health ideals, but disagree about the ethical
content of “mental health” (see Chapter 9). And even when therapists
and societies agree that policies regarding therapy ought to balance a
concern for the mental health of individuals and a contribution to the
general welfare, citizens often disagree about the meaning of “the general
welfare.” Trabin and Freeman (1995) argue that business justifications, an
ideal some therapists think should not interfere with decisions about
therapy, should be included in social policy regarding therapy. From the
perspective of evolutionary ethics, J.Michael argues that “professional
activities should be primarily directed toward the development of social
practices which have lasting cultural survival value” (Michael 1977:303).
Jaggar articulates ethical assumptions she believes are common to
feminists: “the view that the subordination of women is morally wrong
and that the moral experience of women is worthy of respect.” Feminists
are collectively committed, she argues, to working out “the practical and
theoretical consequences of these assumptions, a commitment perhaps
analogous to the projects of those who develop so-called Christian or
Marxist ethics” (Jaggar 1991:95). From a religious perspective, Browning
points out that “health is only one value (albeit a highly important value)
among many values by which the Western religions assess themselves”
(Browning 1991a:26). Environmental ethicists would add concern for the
environment in the mix of goods a society needs to balance in
formulating a public philosophy for therapy. And so, in the face of
convincing claims for many ethical principles, Prilleltensky (1997) argues
for a balance of ideals, a position which I also endorse. But which values
are to be balanced and how they are to be balanced remain in dispute.
Some public philosophies support a broad mandate for therapists, but
others advocate a narrow mandate. The issue, as Browning articulates it,
is whether the mental health profession should “lead society in
developing a positive view of the good society and the good person (or
‘healthy’ society and person), or should it confine itself to the more
cautious role of caring for the mentally ill?” (Browning 1991b:1). Costcutting governments, corporations, and other third-party payers tend to
advocate the narrower mandate, to the dismay of many therapists and
clients.
Although directly related to practical policies, public philosophies draw
upon decidedly abstract philosophical assumptions. Many claim to
decide such issues, not on philosophical, but on “pragmatic” grounds:
“we should do whatever works.” As Tillich noted, however, “most
pragmatism…indulges in a hidden metaphysics” (Tillich 1959:192).
Indeed, argues Browning, a public philosophy “entails the idea that
psychiatry needs in the background of its work general images of the
good person and the good society” (Browning 1991a:20), images that
shape the public philosophy of the psychotherapist.
The claim that we can make valid assertions about “the good society”
is disputed, of course. Indeed, modernity is characterized, MacIntyre
argues, by “the thesis that questions about the good life for man or the
ends of human life are to be regarded from the public standpoint as
230 ETHICS AND VALUES IN PSYCHOTHERAPY
systematically unsettleable” (MacIntyre 1984:119). Disagreement about
this point deeply divides many societies and characterizes the views of
some self-labeled postmodernists. In an act of retrieval, Taylor
documents, however, the ways in which all contemporary thinkers
(including those whom Prilleltensky (1997) labels skeptical
postmodernists) draw upon four inter-related deepseated beliefs, beliefs
that are often hidden from view. These beliefs concern “not just (a) our
notions of the good and (b) our understandings of the self, but also (c) the
kinds of narrative in which we make sense of our lies, and (d)
conceptions of society” (Taylor 1989:105). Explicitness about those
inextricably ethical beliefs, about the philosophical assumptions upon
which any public philosophy draws, will, I believe, facilitate more
fruitful and intellectually satisfying discussions about public philosophy.
Another important dimension of the ethical character of psychotherapy
in a society is the concept of the professional. As discussed in Chapters 2
and 11, professions exist (and continue to exist) because societies agree
they should, to meet particular societal needs (Bassford 1990; Michels
1991). And professionals’ most fundamental principles derive, not from
the profession alone, but also from the society in which they practice
(Browning 1991a; Margolis 1966). In the classical understanding,
professionals are highly trained people whose conduct is governed by a
professional code of ethics and by a preeminent commitment to the
principle of beneficence, a commitment to the well-being of others (see
Hatch 1988a; Jennings et al. 1987). A deep ethical core is thus intrinsic to the
professional. That means, assert Meara, Schmidt, and Day (1996), that
“more is expected” in a professional relationship “than in a contractual,
business relationship” (Meara et al. 1996: 20). Unfortunately, some
economic reductionists (Chapter 7) view therapists in the latter terms, as
nothing more than useful “providers” of “services” who need monitoring
and control. That difference in perception of therapists, and in public
philosophy, is profound. Accordingly, “we need to reappropriate the
ethical meaning of professionalism, seeing it in terms not only of technical
skill but of the moral contributions that professionals make to a complex
society” (Bellah et al. 1985:211).
Having previously addressed the relationships between psychotherapy
and science, medicine, and business (Chapters 6–7), I will not discuss
them further here. I do want to address one set of relationships, that
between therapy and religion, a relationship relevant to Anna’s
depression. The history of the relationship between psychotherapy and
religion is long and complex (Browning 1987; Jones 1994; Shafranske
1996), with periods of harmony and periods of tension. Psychotherapists
have often been portrayed as priests,2 supplanting with their moral
authority a role previously occupied by the dying remnants of religion.
Indeed, Kovacs encouraged therapists to “embrace…our essential role as
secular priests” (Kovacs 1987: 16). Although it is not clear what these
authors mean by “priest,”3 they clearly envisage a greatly expanded
mandate for therapists. And that is a role generally not requested by
those who are religious, at odds with the wishes of many third parties
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 231
paying for therapy, and falling beyond the training received by most
therapists.
Undeterred by (or unaware of) the experts asserting that religion is
dying, Anna and others continue to be religious. Indeed, except in
Europe and some subcultures of the US, most people in the world
continue to be religious, albeit at times in different ways than in the past
(Hoge 1996). Although some who are religious have no interest in the
kind of respectful public conversation about the role of therapy in a
society (or about anything else) that I have described in this chapter,
others are interested (Browning and Evison 1991; Cahill 1990; Jonsen
1994). And some (e.g. Bellah 1986; Benne 1995; Thiemann 1991) are even
developing a “public theology” for the purpose. Indeed, those who want
a public philosophy that is truly public (and not dogmatically antireligious) would be likely to agree that religion “belongs in the
conversation” (Bellah et al. 1991:33).
Wallace adopts a different stance concerning the respective roles of
religion and psychotherapy. In response to criticisms that therapists have
undermined the moral sensitivities of their clients (and, by extension, the
moral tenor of societies), he denies that therapy is “a recipe for amoral
living” (Wallace 1991:112). And he articulates the benefits of therapy. But
he immediately adds an important caveat, suggesting an intimate
relationship between religion and psychotherapy. Psychotherapy, he
argues:
can be a salutary counterbalance to traditional, Judeo-Christianbased ethical judgment—but only if the clinician can count on cultural
institutions to do their moral and cosmological job. If not, then
understandably patients will look to psychiatrists for meaning and
morality, and getting them becomes part of the healing itself (as is
explicit in the “ego lending” and “limit setting” required by some
patients nowadays). Hence it is not only very difficult to rid the
psychiatries of their metaphors of ultimacy and obligation, but it
would perhaps be, at least for many patients in the current climate,
a serious therapeutic and moral error to attempt to do so.
(Wallace 1991:113)
Given what Himmelfarb (1995) describes as the “demoralization of
society,” the optimal role of therapy in society may need rethinking.
Writing in an American context, Wallace can be reasonably sure
that most “cultural institutions” are “Judeo-Christian.” In other parts of
the world and in subcultures not heavily influenced by that religious
tradition, the relationship of culture and psychotherapy would need to
take a different form. Any adequate public philosophy must grow out of
that society’s culture or cultures.
232 ETHICS AND VALUES IN PSYCHOTHERAPY
Deciding the role of therapy in a society
Faced with any decision, many psychotherapists turn on first impulse to
science. And science can be very helpful (Kiesler et al. 1991; Lorion et al.
1996; Speer and Newman 1996), especially when we agree about a
desired goal that we can measure. If we agree about what constitutes
therapeutic effectiveness, for instance, scientific evidence may have clear
implications for public policy and for professional ethics. Chambless and
his colleagues provide this vivid example:
To take an extreme and hypothetical example, therapists might
know of only one intervention consistent with their theoretical
orientation that has been empirically supported for a specific
problem. Let’s say research has shown it to be efficacious in 73% of
the cases after a 3-year course of treatment. Are those therapists
acting ethically if, because they do not read outside their own area of
interest, they remain ignorant of an intervention associated with
another theoretical orientation that has been repeatedly shown to be
effective in 94% of the cases after a 5-week course of treatment?
(Chambless et al. 1996:1996:113)
From that empirical finding, appropriate public policy would clearly
follow.
Unfortunately, when public philosophies (and the public policies
related to them) are discussed, the goal is often in dispute. And, as
Krause and Howard note, “traditional scientific method does not concern
itself with the issue of conflicting interests” (Krause and Howard 1976:
291). Indeed, Kendler (1993) argues that we cannot draw valid ethical
conclusions from scientific findings alone. Policy decisions are based
instead, Strupp (1986) argues, on a society’s values (the ethical
convictions of its members) concerning mental health. And on its values
regarding other good societal ends.
Making decisions about the ethical dimensions of a public philosophy
regarding therapy is similar in many ways to making any kind of ethical
decision: for instance, the ethical negotiating that occurs between
therapist and client concerning therapy goals and process. And so the
discussions in Chapters 4, 8, and 9 (and that to come in Chapter 12) are
relevant. Respectful dialogue among therapy stakeholders (Jahoda 1958;
Strupp and Hadley 1977), sound ethical reasoning, drawing upon ethical
traditions with an openness to new solutions, compromise, the use of
multiple ideals, participants being aware of and articulating their own
ethical stances, and upholding autonomy are all important.
Negotiating a public philosophy can be even more difficult, however,
for several reasons. The range of ethical differences may be greater. And,
because decisions affect an entire society, the stakes are much higher.
Empirically derived findings may be more directly relevant, and so
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 233
interpretation of their meaning is especially important. Hammond,
Harvey, and Hastie (1992) argue that policy-makers need to take into
account both the error of failing to take action when it should have been
taken (e.g. a third-party payer failing to authorize additional sessions for
a suicidal client) and the error of taking action when it should not have
been (e.g. therapists seeing clients when they need no more sessions). To
determine the proper balance between those false negative and false
positive decisions is, they note, “a value question.” Vested interests,
however, may want society to ignore findings that do not match their
point of view.
Unfortunately, no problem-solving strategy can guarantee certain
answers. As Callahan points out,
The first and most important point to make is that there exists no
simple, mechanical formula, either in ethics or in policy, for
devising solutions to difficult balancing and priority issues…. I have
constantly used terms such as “reasonable,” “sensible,” and
“prudent”—terms of human art and judgment. I believe these to be
the right terms to use, however vague and controverted they are
and must remain. But that is the nature of our problem. It requires
judgment, not formulas.
(Callahan 1990:160)
Because of the complexities involved, Jennings, Callahan, and Wolf link
“public philosophy” and “civic discourse,” describing them as “that
ongoing, pluralistic conversation in a democratic society about our
shared goals, our common purposes, and the nature of the good life in a
just social order” (Jennings et al. 1987:6). A broad perspective needs to be
adopted, in part because the ways in which therapists move people
toward mental health, or, better, the kind of “mental health” toward
which therapists move people, profoundly affects a society. All strata of a
society need to be involved, not just those who see clients, pay taxes,
administer bureaucracies, and run corporations.
But a profound difficulty faces that idealistic inclusiveness: deep
ethical differences divide many societies. Imposing the views of the
majority on the minority will not produce a satisfactory public
philosophy. And expecting everyone to live on the basis of some bland
lowest common denominator, some ethical consensus that neither
offends nor inspires, produces its own set of problems. And the evertempting “solutions” of relativism and authoritarianism will also fail us.
It is to wrestling with alternative solutions to the problem of ethical
diversity that I turn next.
234 ETHICS AND VALUES IN PSYCHOTHERAPY
Addressing ethical diversity
The ethical differences underlying the different conceptions of mental
health and other therapy goals discussed in Chapter 9 are but part of the
ethical diversity facing those designing a public philosophy for
psychotherapy. Engelhardt begins the acclaimed second edition of his
Foundations of Bioethics by acknowledging that “there is a swarm of
alternative ethics ready to give rise to a babble of conflicting bioethics. This
circumstance constitutes the foundational moral challenge of all healthcare policy. It brings the very field of bioethics into question” (Engelhardt
1996:vii).
Competing within Anna’s society may be African (Magesa 1997; Paris
1995); Buddhist (Ray 1994); classic liberal; Communist; feminist; Hindu;
Marxist; materialist; Native American; neo-conservative; paleoconservative; secular, Reformed, and Ultra-Orthodox Jewish; Roman
Catholic, Orthodox, liberal, moderate, evangelical, and fundamentalist
Christian; Shinto; sociobiological; Taoist; and other ethical stances. Values
differ between countries and between subcultures within societies
(Marsella and White 1982; Minsel et al. 1991; S.H.Schwartz 1994). And
deep differences exist within the major Western intellectual tradition,
despite superficial consensus (Taylor 1992). Of particular relevance to this
book is the attack by Nietzsche (who has deeply influenced Freud and
many postmodernists) on benevolence (Taylor 1989), an ethical principle
central to the concept of the professional.
In response to this pluralism, various communities, such as the
feminist, attempt, in Jaggar’s words, “to develop distinctive ways of
living and thinking that reflect fundamental normative commitments
currently shared by only a limited community” (Jaggar 1991:95). And
religious communities, to the surprise of many Western intellectuals,
continue to serve as a moral source for many people. As Marty points
out:
Since the Enlightenment two centuries and more ago, the instinctive
projection of scholars and sages in the West was to foresee a world
in which religion progressively declined. They advanced this
projection by envisioning that surviving religions would be modern,
progressive, friendly to mainstream science, tolerant, interactive.
Students of modern religious fundamentalism instead find that
there seems to be as much religion around as ever, and that the
prevailing movements are closer to fundamentalisms than to
modernisms.
(Marty 1993:4)
And investigations of fundamentalisms (Marty and Appleby 1991, 1992,
1993a, 1993b, 1994, 1995, 1997) make it clear that fundamentalists
are patriarchal. And they are deeply concerned about such psychological-
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 235
ethical issues as “gender, sexuality, intimacy, familiality, {and} the life
cycle” (Marty 1993:5). Public philosophies concerning therapy need to
take into account the concerns of both feminist and fundamentalist
communities, since their conflicting convictions overlap extensively with
the ethical issues addressed in therapy. And many other communities
exist within societies as well, including communities of religious
feminists.
I do not believe that a satisfactory public philosophy can be based on
only one of those competing options, even if it represents the convictions
of the majority of the members of a society. This is true whether Anna is a
Unitarian in a fundamentalist Muslim country or a devout, conservative
Muslim in a Western liberal democracy. A public philosophy based solely
on one ethical perspective might mean that its ethical vision would be
imposed on those holding other views. And, as Engelhardt points out,
there would be no difference between imposing on people “a Roman
Catholic contraceptive policy” and “a Rawlsian theory of justice”
(Engelhardt 1991:xiii; see Quinn 1995).
Attempts to ground ethics on an indubitably certain foundation—
whether in theism, disengaged reason (which has profoundly influenced
psychology through its marriage to empiricism in the scientific method),
or the depths of the self (e.g. in the ethical tradition of humanistic
psychologists like Rogers and Maslow)—have failed (Taylor 1989). Many
believe that reason (including the efforts of Rawls 1971) has produced
neither the agreement nor the certainty that many (traditionalists and
postmodernists) insist that a satisfactory ethics must exhibit. “For better
or worse,” Smith argues, “we are stuck in a pluralistic society and world
in which there is little prospect of our agreeing on first premises”
(M.B.Smith 1990:532). And those profound ethical differences have
produced in the US what has been dubbed “Culture Wars,” associated
with political differences that are very deep (Hunter 1991).
The problem is quite real. As Engelhardt points out, “Diversity is not
only engaging. Diversity with substance offends” (Engelhardt 1996:14).
And that makes developing a public philosophy regarding an
inextricably ethical activity like psychotherapy very difficult indeed.
Nevertheless, several potentially fruitful approaches exist. All are
disputed, of course, and the debate among bioethicists, philosophers, and
political theorists is intense. But after some preliminary considerations, I
will consider four potentially fruitful proposals for dealing with ethical
diversity in developing a satisfactory public philosophy for therapy: a
limited role for therapists, a focus on consensual ethical content for
therapy, making room for a variety of approaches to therapy that meet
basic standards for therapy but grow out of the particular convictions of a
given ethical community, and the development of an ethic to deal with
those “moral strangers” (Engelhardt 1991:xiii) whose ethical convictions
are deeply at odds with one’s own.
Several steps are preliminary to progress: clarifying and articulating
the views of all therapy stakeholders, especially those with deeply
236 ETHICS AND VALUES IN PSYCHOTHERAPY
differing ethical perspectives. This serves as a vital preface to a dialogue
or “common discussion” (Bellah et al. 1991:66) among those with radically
different points of view. That can increase understanding and pinpoint
ethical commonalities previously undetected. However, stakeholders also
need to acknowledge where deep differences exist. Finally, I think it
helpful to have some sense of the extant alternatives and the conflicts that
exist (a map of the ethical terrain, if you will). That, of course, is a major
reason I have written this book.
To deal with ethical diversity, some argue for a tightly delineated role for
psychotherapists. Advocates of this first proposal contend that a public
philosophy should involve narrowly focusing therapy on its original task
—helping those with serious psychological problems so they experience
less distress and function more effectively. The goal: mental health as
freedom from mental illness. Michels argues, for example, that “a vital
guiding principle in outlining a public philosophy for psychiatry is to
maintain a clear boundary” between tasks falling within the profession’s
domain and those falling outside of it (Michels 1991:72). And so he would
reject the claim that therapists should “embrace” the role of priest.
Indeed, he argues that the profession “should be sharply critical of those
who ignore or intentionally blur that boundary in order to enhance the
public credibility of their positions” (ibid.). Advocates of this view
encourage therapists to minimize their ethical influence on clients, as
discussed in Chapter 8. By avoiding (or adopting as neutral a stance as
possible regarding) ethically controverted topics, therapists are less likely
to violate rights of clients from minority ethical subcultures. Or to
convert them to the ethical convictions of the therapist. And limiting the
range of a therapist’s actions makes it less likely that the ethical majority
in a society will impose its ethical stance on persons with minority ethical
viewpoints. Furthermore, therapists limit their professional actions to
those for which they have competence and contract (Tjeltveit 1986).
Finally, some third-party payers may espouse this tightly delineated
understanding of the proper location of therapy in a society, not because
of a carefully articulated, profound, or morally elevated philosophical
rationale, but because it is cheaper.
Although advocates of this view claim it to be both feasible and
desirable, I am less convinced than I used to be that it is either humanly or
philosophically possible to draw crisp lines that delineate a narrowly
ethical role for therapists. Also unanswered, of course, are the details
concerning this limited role of the therapist: to which roles are the
activities of the therapist to be limited? are therapists limited to the
traditional individualistic, egoistic, and selfish influence on clients? or can
therapists free people from mental illness in a way that balances concern
for self with concern for others? As for the desirability of this proposal,
advocates of the other three proposals argue that a tightly delineated role
is not the best way to address ethical diversity, and the ethical character of
therapy, in a public philosophy.
Consensus, properly conceived, may permit the development of a
public philosophy regarding therapy that addresses the problem of
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 237
ethical diversity, either completely or in part. Advocates of this second
proposal assert that, even in the midst of significant ethical diversity,
members of a society ought to be able to articulate a consensus, in ethical
terms, of therapy’s purpose. This may take the form, for example, of
consensual mental health values to which the profession adheres and
which actual therapy, properly conducted, exemplifies. But “consensus”
is used in a variety of ways. So, let me first unpack some of the varied
meanings of the term. Alternative positions, and their merits, can then be
discussed.
Some assume that a consensus has, or should have, only one
underlying source; others assume a consensus has many sources (people
of differing views agree about one issue although not agreeing about
others). Advocates of the former view may assume that reason, proper
rational procedure, scientific evidence, or an optimal type of dialogue
will produce consensus. Reason, according to Rawls (1993), is the basic
source from which an “overlapping consensus” can be built. Consensus
develops from that one source; if those who disagree would align
themselves with that source, they would come into harmony with the
consensus. Or, to put the matter in crass terms that clearly overstate the
case, “genuine consensus must come on my intellectual terms, terms I
regard as rational and universally applicable.”
Advocates of the view that diverse ethical convictions produce
whatever consensus can be achieved are not sanguine that one source can
produce consensus. Indeed, Rawls succeeds in obtaining a consensus,
Ballard (1996) claims, by excluding concepts of good that conflict with his
own understanding of liberalism. Jaggar points to the growing consensus
that “reason is culturally constituted” and that “the rules of inference
taken to define rational argument cannot be justified independently of
social agreements about what kinds of inferential moves are acceptable.”
The result, she argues, is “an understanding of ethics as plural and local
rather than singular and universal, grounded not in transcendent reason
but rather in historically specific moral practices and traditions” (Jaggar
1991:93). This view has two implications. First, the most substantial forms
of ethics occur in particular ethical communities (which hold some views
that others do not hold) rather than on universal terms (across an entire
society). (Consistent with this view, some propose that forms of
psychotherapy that are consistent with a local community’s ethical stance
become an acceptable alternative to the standard “one size fits all ethical
convictions” variety of therapy. I will return shortly to that alternative for
handling ethical diversity.) Second, societal consensus arises from diverse
ethical sources. For example, Anna’s minority religious perspective and
the majority perspective in her culture may, for fundamentally different
reasons, support the elimination of her depression. But
those perspectives may disagree about fundamental standards of reason
to adjudicate their other differences conclusively. Likewise, a classic
liberal (religiously agnostic), a devout theologically moderate Christian,
and a practicing Reformed Jew may all concur with Jaggar’s rejection of
the oppression of women, but for reasons quite different from one
238 ETHICS AND VALUES IN PSYCHOTHERAPY
another, reasons based in part on metaphysical, epistemological, and
ethical assumptions they do not share. Those who support particular
ethical perspectives, those of local communities, may value reason. But
they do not believe that reason will provide full-fledged ethical
convictions of sufficient depth and richness for human flourishing. A
secular public philosophy can be developed, but of necessity it must be
sharply limited in scope (Engelhardt 1996).
Commentators employ a variety of metaphors to describe an ethical
consensus produced by reason in contrast to other ethical perspectives.
Universal ethics is contrasted with local ethics, and thin with thick. The
ethical gruel produced by consensus is said to be thin, thin enough to be
affirmed by consensus but insufficient to sustain and nourish people, no
less permit them to flourish. Engelhardt (1991, 1996; Engelhardt and
Wildes 1994) contrasts positions lacking moral content (and so of little aid
in deciding therapy goals or a public philosophy for psychotherapy) with
content-full ethical perspectives, those that have “moral substance.” For
that, argues Taylor (1989, 1992), people need ethical articulacy, articulacy
concerning moral sources capable of moving people. Those who claim to
hold no ethical views (or who affirm basic bioethical principles like
justice and autonomy but deny holding any particular ethical theory) are
said to be living off the ethical capital deposited by previous generations,
to be drawing upon an ethical heritage that shaped them but which they
now deny. They are, Engelhardt and Wildes (1994) argue, “covertly
presupposing” a more substantive ethical stance, a stance not the product
of reason alone, a stance about which there is not societal consensus.
Deep moral sources, it is claimed, are necessary to provide the motivation
and the content to live optimally ethical lives. The thin ethical principles
derived by consensus are insufficient to move a person to understand or
live the good life. They are psychologically impoverished.
The nature of any consensus that a society develops is in dispute in
other ways as well. Bellah, Madsen, Sullivan, Swidler, and Tipton argue
that it would be good to “create an American public philosophy less
trapped in the clichés of rugged individualism and more open to an
invigorating, fulfilling sense of social responsibility” (Bellah et al. 1991:15;
cf. Drane 1991). And Doherty aspires to “a new cultural ideal in which
personal fulfillment will be seen as part of a seamless web of
interpersonal and community bonds that nurture us and create
obligations we cannot ignore and still be human” (Doherty 1995:20). But
whatever the virtues of their positions, the consensus they describe does
not now exist in American society.
Various approaches to identifying an ethical consensus have been
attempted. Through a process of rational analysis, Bok (1995) identified a
set of common values adhered to across the world.5 And empirical
researchers have identified some areas of broad consensus concerning
values related to mental health and psychotherapy (Jensen and Bergin
1988; E.W.Kelly 1995a). Engelhardt describes a form of secular humanism
(which, unlike other forms of secular humanism, is not anti-religious)
that entails a consensus about procedural rules for living. This “restricted
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 239
moral vision” serves as a common moral language for those from
differing ethical perspectives and as a “coherent statement” of the “way
of life” lived by those he labels cosmopolitans (Engelhardt (1991:125, 139).
Cosmopolitans, he argues, “are men and women who have shed
intensely held, content-full understandings of life, health, medicine, and
death that focus on moral ultimates. Their lives are constructed around
instrumental goods, not ultimate moral commitments” (ibid.: 146).
Those forms of consensus are important, especially consensus about
the values affirmed by most therapists. As Michels argues, clients should
be able to assume that therapists represent “a set of values defined by a
professional group” (Michels 1976:382). Identifying those values is
therefore important.
Unfortunately, the usefulness of those types of consensus for
developing a public philosophy for psychology may be limited, for three
reasons. The mere existence of a consensus does not tell people why they
should believe in those ethical convictions. That people believe in certain
values tells us nothing about whether it is good they do so. Indeed, as we
have seen, therapists may affirm autonomy, for example, for a variety of
ethical reasons. Second, many people find such a consensus to be “too
thin” intellectually, too psychologically impoverished, and too general to
be of practical worth. (I will return to this issue in Chapter 12.) Finally,
merely delineating a consensus provides no guidance to deal with those
clients, therapists, and subgroups within a society who disagree with
elements in the consensus or who hold more particular ethical views
(whose convictions extend beyond, or in some way dispute, consensual
ethical views), for instance, people affirming minority (dissenting) views.
Communitarians (Etzioni 1993) and others have sought to define some
common vision of the public good. In doing so, they separated from
classic liberals, who have traditionally believed, MacIntyre asserts, “that
government within a nation-state should remain neutral between rival
conceptions of the common good” (MacIntyre 1994:302). It is not clear to
me how governments can remain neutral. Indeed, if they provide funds
to treat mental illness, it is surely in part because they believe that the
nation’s citizens, and the nation as a whole, will be better off with
mentally healthy rather than mentally ill citizens. But the concern
MacIntyre raises about the authoritarian dangers of an imposed
“consensus” is well-taken (see Bersoff 1996). Part of the solution may be a
modest vision of the common good, some low-level consensus. “It is good
for citizens to receive effective treatment for mental illness” seems a good
candidate, one that would receive wide assent and is not susceptible to
authoritarian interpretations. But those holding ethical views not
universally held need protection. For that and other reasons, the
following two proposed solutions offer promise in helping crafters of a
public philosophy for therapy to address ethical diversity well.
If ethical diversity finds concrete expression in the experiences and
convictions of particular communities, affirming forms of therapy that are in
accord with particular ethical communities stands as a third alternative for
dealing with ethical diversity in a public philosophy for therapy. This is
240 ETHICS AND VALUES IN PSYCHOTHERAPY
consistent with the claim that all forms of substantive (“content-full”)
ethics arise among those holding particular sets of ethical beliefs. As
Engelhardt put it:
there is no univocal way in general secular terms to discover a
priori the meaning of health, suffering, illness, death, or the
purposes of medicine. Such meaning must from a secular
perspective be fashioned by actual communities and individuals in
real circumstances.
(Engelhardt 1991:136)
This third proposal would require the acceptance of, or finding place for,
a variety of ethical communities within the psychotherapy professions.
These communities may be geographically or otherwise isolated (the
Amish) or may actively interact with those holding other views. They
may be intellectual communities, historical communities, or communities
involving concrete relationships with other persons.
This proposal would benefit “minorities,” like Anna, whose deepest
convictions about life are not shared by those in her society. But it would
also benefit those whose ethical convictions are widely, but not
universally, held. These psychotherapy clients could recover from their
psychological problems in a way that is consistent with the beliefs they
hold as members of an ethical community. And those seeking a more fullorbed state of psychological flourishing could do so in a therapeutic
relationship that meshes with their beliefs about ideal human functioning.
Feminist clients may want to work with a therapist who is also
committed to the feminist community, a community that, Jaggar
suggests, is “seeking to develop distinctive ways of living and thinking
that reflect fundamental normative commitments currently shared by
only a limited community” (Jaggar 1991: 95). And if a potential client is
concerned, like Cushman, “to collude less with contemporary capitalism
and actually develop ways of treating the primary causes of psychological
ills, the political and economic structures” (Cushman 1992:58), he or she
could seek a therapist, like Cushman, who shares those beliefs. With client
and therapist sharing the same ethical community, the long-term result
may be, as Cushman notes, “a much greater healing.”
Clients and therapists would be drawing upon a variety of deeper
moral sources, upon what Engelhardt calls “the post-modern pluralism
of moral visions” (Engelhardt 1991:140). This “more consistently
inclusive” pragmatic pluralism (Marsden 1991:46) could include the full
range of ethical theories mentioned in this book. Engelhardt provides a
non-inclusive list: “tradition, culture, and God’s good grace” (Engelhardt
1991:195).
This proposed solution to the problem of ethical diversity carries its
own set of potential problems. As with any attempt to match particular
types of clients with particular therapists, logistical challenges would
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 241
arise, especially in sparsely populated or underserved areas. More
substantive problems may arise as well. Too much ethical diversity (with
as many forms of therapy as there are ethical communities) would call
into question the very meaning of psychotherapy. Some basic standards
for therapy (pertaining to a consensual core of therapy values) may be a
solution, however.
This proposal also does not provide a solution to the person genuinely
confused about ethical issues or holding few or no clear ethical
convictions. In addition, professional ethical problems may also arise,
especially concerning informed consent (to be discussed in Chapter 11)
and the need to insure that clients who change their minds about
receiving a form of therapy associated with a particular ethical
community can freely withdraw from that form of therapy if they choose
to do so.
But in the absence of therapy targeted to the ethical community of
clients, or for those circumstances in which therapist and client, or
therapist and society, have deep ethical differences, therapists and a
society need to adopt an appropriate ethic for working with “moral
strangers”. This fourth proposal to deal with ethical diversity borrows
Engelhardt’s felicitous terminology to refer to those whose ethical
convictions are deeply at odds with our own. He uses the phrase, “to
signal the relationship people have to one another when they are
involved in moral controversies and do not share a concrete moral vision
that provides the basis for the resolution of the controversies, but instead
regard one another as acting out of fundamentally divergent moral
commitments” (Engelhardt 1991:xiii).
An ethic for moral strangers is without content (Engelhardt 1991),
because to introduce some content might entail imposing one’s moral
views on another, one of the problems related to ethical diversity that this
proposal is supposed to address. But it is an ethics that provides
therapists with “a way of reaching across traditions” (ibid.: 135), such as
the feminist therapist encountering a fundamentalist Christian, or a
staunchly pro-life Catholic therapist working with a pregnant pro-choice
young adult. This ethic, closely tied to professional ethics, must include a
substantial measure of tolerance and respect for the views of the moral
strangers (which does not mean therapists must either agree with their
views or adopt a relativist stance). And, of course, therapists must uphold
the autonomy of clients.
Therapist efforts to persuade these moral strangers to adopt their
own views (e.g. to convert a client concerned only with self to an ethic in
which care for children plays some role) raises questions of professional
ethics that were discussed in Chapter 8 and will be addressed again in
Chapter 11. To surreptitiously or aggressively hawk one’s own views—
however noble or well intentioned those views might be—would be a
clear violation of this ethic. No public philosophy for psychotherapy
could countenance that trampling of client autonomy.
In summary, I have discussed four proposals to address the deep
ethical diversity that bedevils efforts to construct a public philosophy for
242 ETHICS AND VALUES IN PSYCHOTHERAPY
psychotherapy, a profoundly and inextricably ethical endeavor. These
four proposals—a tightly delineated role for therapists, consensus,
affirming forms of therapy that are in accord with a particular ethical
community, and an appropriate ethic for working with “moral
strangers”—all have strengths and weaknesses. Ethicists and social
philosophers will continue to debate them. For the purposes of
constructing a public philosophy for psychotherapy, however, we may
not have to choose between them. Solutions that draw upon each and
keep all four in tension may be optimal. Again, however, the design of an
optimal public philosophy for a particular society is a task, not for the
author of a book on ethics and values in therapy, but for members of that
society.
Whatever public philosophy a society constructs, however, that
philosophy finds expression in contracts related to psychotherapy.
Revised social and therapeutic contracts
Growing out of a society’s public philosophy are contracts pertaining to
psychotherapy. The therapeutic contract (Orlinsky 1989) addresses the
relationship between therapist and client (and, if therapist and client
agree, third parties that pay for some portion of the therapy). And the
social contract (Michels 1991) is an agreement (usually implicit) about the
location and role of psychotherapy within a society. In addition to
addressing practical details (like payment and session lengths), both
types of contract have an ethical quality. The therapeutic contract,
Orlinsky notes, “governs the system through the normative expectations
set for patients and therapists” (Orlinsky 1989:430). And the social
contract, Parloff argues, has to do with therapeutic goals, and especially
therapy’s ultimate goal, which reflects value judgments. That ultimate
goal, he asserts, “is the principal concern of the therapist in fulfilling his
{or her} contract with the patient and community” (Parloff 1967:8).
I am using contract as a term of art, of course, because therapist and
client only occasionally literally sign a contract. And those they do sign
are rarely legally binding. “Social contracts” are, of course, never signed.
Both types of contract refer to generally agreed-upon understandings
about the nature and role of psychotherapy. Movies, television, and
books create them, with accountants, politicians, and health planners
contributing as well. In addition, the writings of professional
psychotherapists, and discussions between therapists and clients play a
role. An absence of a dutifully signed legal document does not, however,
rob these contracts of their force, because they shape expectations about
therapy. When working as a family therapist on an inpatient psychiatric
unit, I was struck by how often family members encouraged one another
to self-disclose, often moments after I had met them: “This is the place to
open up about everything. It’s safe to talk about it here.” Expectations
RETHINKING PSYCHOTHERAPY’S LOCATION IN A SOCIETY 243
about therapy were so deeply engrained in American culture that I had
no need to set them forth explicitly.
The idea that contracts are with therapist, patient, and community
(Parloff 1967) expands psychotherapy theorists’ traditional emphasis on
the therapeutic dyad. Although therapy has always occupied some
cultural space within a society, within particular sociohistorical contexts
relevant to therapy’s ethical character, agreements about therapy
increasingly include third parties: government entities, corporations, and
various other third-party payers. As Orlinsky (1989) notes, “special
complications” arise when parties other than therapist and client have a
direct role in the therapeutic contract, including the de facto ability to end
a therapeutic relationship by denying payment. In many (but not all)
cases, therapists and clients invite the participation of these other entities.
But those third parties, which often interact with clients and therapists
through obscure bureaucracies, often fail to specify clearly the nature of
the relationships among therapist, client, and the third party. This causes
confusion and impedes the provision of effective therapy, which is not
good.
That potentially deleterious impact of contracts is the first reason
contracts are relevant to the ethical character of psychotherapy. The
second is that contracts have an ethical character related to the location
they assign to therapy within societies. Finally, the implicit contract
governing psychotherapy may falsely promise a level of value-freedom
that therapists cannot provide. And so clients may assume therapists will
not make any ethical judgments about them and will not influence their
values. But therapists inevitably make ethical judgments about their
clients, a wide range of ethical judgments, although therapists rarely treat
clients “judgmentally” and many of their ethical judgments are nonmoral
rather than moral. And therapists may well influence client values
(Beutler and Bergan 1991). For all those reasons, contracts regarding
therapy deserve close attention.
Ideal contracts pertaining to therapy make clear what all parties can
expect so they can make informed decisions about participating. If
feasible, therapists and clients who disagree with the operative values of
particular third-party payers should not enter into relationships with
them. They have the right, of course, and perhaps the responsibility, to
work within their society to insure that the kind of therapy they want is
available.
With regard to the ethical character of therapy, explicit and implicit
promises that therapy will be value-free are both inappropriate.
Therapy’s inextricably ethical character should become part of social
contracts about therapy, part of the cultural consciousness about therapy,
just as the idea that therapy is a safe and confidential place to talk about
personal problems is now.
Given the existence of current social contracts which imply that
therapy is ethically neutral and the existence of ethical diversity in
societies (and among therapists), therapists often address the ethical
character of therapy best of all through explicit discussion. Because
244 ETHICS AND VALUES IN PSYCHOTHERAPY
therapists disagree among themselves about ethical ideals related to
therapy and because their ethical ideals influence the therapy they
provide, therapists actually provide a variety of “psychotherapies” rather
than an ethically uniform type of relationship. If, for instance, Anna’s
therapist has definite views on abortion that diverge from those held by
Anna, the role of that therapist’s ethical convictions (and likely
persuasive influence) may belong in the therapeutic contract established
in dialogue with Anna. As Veatch (1973) pointed out, clients
appropriately trust professional judgment when agreement about goals
exists, but not when disagreement is present. Given ethical diversity and
the persisting belief that therapy is value-free, the therapeutic contract
ideally addresses ethical issues when therapy stakeholders hold different
ideas about therapy goals.
In conclusion, social contracts pertaining to therapy grow out of a
society’s understanding of the location of psychotherapy within it, an
understanding ideally articulated in a public philosophy for
psychotherapy. Therapeutic contracts grow out of implicit and explicit
agreements between therapists and clients (and often third parties). Both
types of contract (and public philosophies) should address the ethical
character of therapy. As I have noted, however, it is often difficult to do
so, especially when ample ethical diversity prevails. In the absence of
clear contracts, therapists need to attend closely to the principles of
professional ethics when addressing the ethical character of therapy.
11
Profession and professional ethics
Psychotherapists are professionals. Such is the affirmation of the public
philosophies regarding therapy in most societies, most social and
therapeutic contracts, many public policies, and most psychotherapists.
It makes a difference whether or not Anna, the depressed woman
discussed in Chapter 10, turns to a professional for help. Or it should
make a difference, because being professional implies therapist concern
for clients and commitment to certain ethical standards.
In applying standards of professional ethics to the therapy Anna and
others receive, however, therapy stakeholders may assume that therapy
is value-free, or minimally or uncontroversially value-laden. In light of the
richer understanding of the ethical character of psychotherapy now
developing, some dimensions of professional ethics need rethinking,
especially with regard to situations in which contested ethical issues arise
in therapy, in which therapist and client hold different values (ethically
understood), and in which therapist and client affirm disparate ethical
theories. Anna’s status as a member of minority religious group may be
relevant—if her beliefs about what is good, right, and/or virtuous differ
from those of her therapist or if she holds those beliefs for different
reasons.
The existence of ethical diversity and the disguised nature of much of
therapy’s ethical character together raise another set of questions: why do
professions, and individual therapists, commit themselves to a set of
shared ethical principles and behaviors? and from what sources (ethical
theories, personal motivations, etc.) do the full range of therapist ethical
assumptions and characteristics arise? For example, for what reasons—
intellectual and motivational—does Anna’s therapist seek to benefit her
and practice in accord with professional standards of ethics? And what is
the source of the therapist’s other ideas about what is good and best in
life?
In this chapter, then, I will address the ethical character of being a
professional, and especially a professional psychotherapist. I will address
some ways in which traditional assumptions about practicing ethically
may need to be reconsidered in light of therapy’s deeply and indelibly
ethical character. Finally, I will touch upon the psychological and
intellectual sources of the professional’s ethics.
246 ETHICS AND VALUES IN PSYCHOTHERAPY
Profession
When psychotherapists assert that they are professionals, they announce,
they profess, they make public testimony that they possess specialized
knowledge and technical skills that help people with psychological
problems. But there is more. A “public declaration” of a certain sort,
notes Pellegrino:
defines a true “profession” and separates it from other occupations.
The very word comes from the Latin profiteri, to declare aloud, to
accept publicly a special way of life, one that promises that the
profession can be trusted to act in other than its own interests.
(Pellegrino 1989:68)
And so more is expected of the professional than of the craftsman
(Wallace 1991), the owner of a business (Meara et al. 1996), and the
layperson.
Beneficence is the “more” that sets apart professionals, including
professing psychotherapists. “The sine qua non of the professional
relationship,” argues W.F.May (1984:261), is “the virtue of benevolent
service.” Anna’s therapist, if a professional, will (with some
qualifications) put Anna’s interests above his or her own while providing
professional services to Anna. Indeed, Pellegrino asserts that “some
degree of effacement of self-interest…is morally obligatory on health
professionals” (Pellegrino 1989: 58). Although critics of professionalism
have questioned the extent to which professionals actually exemplify that
ideal, Thompson argues that beneficence is the “core duty” of the helping
professions (Thompson 1990:105).1 This classic emphasis has been
expressed in a variety of ways. Professionals are characterized by:
“service” (Raimy 1950:19), contributions to society (Bellah et al. 1985),
“social responsibility” (American Psychological Association 1992:1600;
K.S.Kitchener 1996a:361), “responsibility for the whole of society”
(Sullivan 1995:11), “concern about the common good” (Meara et al. 1996:8),
and “special responsibilities to look out for the welfare of the client” (ibid.:
20). As Wallace put it, “By virtue of this professed vocation and the
patient’s suffering plea for help, a serious moral claim is made on the
doctor, not merely for scientifically informed treatment, but for caring
and compassion as well” (Wallace 1991:112).
Railing angrily against this ethical core, Nietzsche and skeptical
postmodernists who draw on his thinking reject benevolence. “Taking a
fateful turn against the Enlightenment,” notes Taylor, Nietzsche
“declared benevolence the ultimate obstacle to self-affirmation” (Taylor
1989:343). “Nietzschean professional” is thus oxymoronic: Nietzscheans
disdain the beneficence that is essential to the professional. Nietzsche
held that benevolence is either destructive to the professional’s
fulfillment, or a mask of concern covering the professional’s real
motivation: gaining power over others. Neo-Nietzscheans can find
PROFESSION AND PROFESSIONAL ETHICS 247
evidence for both claims, of course. Foucault (1965), for example, reported
on malevolent displays of power masquerading as professional
beneficence in Madness and Civilization. But to leap from “Expressions of
concern for others sometimes mask hegemonic intent” to “All
professionals, including therapists, who claim a commitment to their
clients are really trying to control them” is a non sequitur. Rather than
drawing that illogical conclusion, I think it best to understand the
Nietzschean critique as a helpful cautionary cautionary tale about
professional abuse of power.
Professional ethics extends far beyond a vague, general concern for
clients, of course. Codes of ethics specify professional ideals and
responsibilities. Although codes have sometimes focused as much on
protection of profession (guild) as on the actions of professionals (e.g.
Starr 1982), current codes clarify aspirational and obligatory therapist
behaviors. Because professionals are members of a “moral community”
(Pellegrino 1989:69), they employ professional codes of ethics to
discipline members of a profession who violate those codes. Successful
lawsuits against therapists who violate current standards of ethical
practice enforce the codes and give additional reason for therapists to
conform to their strictures. Finally, the self-regulating tradition of
professionals is reinforced when ethics codes are incorporated into the
laws (and other government regulations) that govern professional
licensure. Violation of the profession’s ethical code can thus remove the
violator from the societally sanctioned ranks of that profession.
And so psychotherapists are professionals, and professionals qua
professionals are necessarily committed to certain ethical standards.
Philosophical grounds for the ethical character of professions have been
proposed as well (Camenisch 1983; Fulford 1989; Pellegrino and
Thomasma 1981; W.M. Sullivan 1995). We are, however, far from
agreement about those grounds. And some professions, like medicine
and psychology, give far more attention to their scientific than to their
ethical character.
Because “professional” implies ethical character and content, the idea of
“A professional psychotherapist possessing neither ethical convictions
nor concern for clients” is a contradiction in terms. Therapists claiming to
be professionals promise to exhibit beneficence and to practice in accord
with the profession’s code of ethics. And that includes the ways in which
they address the ethical character of therapy.
Professional ethics and the ethical character of
psychotherapy
That psychotherapy has a deeply ethical character, an ethical character
far broader and deeper than professional ethics, is a central claim of this
book. The relevance to psychotherapy of professional ethics, of principles
and virtues particular to the professionals practicing psychotherapy,
needs reexamination, however, in light of the growing recognition of
248 ETHICS AND VALUES IN PSYCHOTHERAPY
therapy’s pervasively ethical character. I will address two issues: the
tension inherent in therapists’ dual commitment to clients and the
general welfare, and the relevance of professional ethics to therapists’
ethical influence on clients.
Commitment to clients, commitment to society
Principles of professional ethics pertain to an issue addressed by social
ethicists: the tension between therapy professionals’ commitment to
individual clients and their commitment to society. Although codes of
professional ethics mandate a focus on the person seeking services from a
professional, they often stipulate a concern for the common good as well.
The preamble of the American Psychological Association’s (1992) code,
for instance, states that the goal of applications of psychological
knowledge is “to improve the condition of both the individual and
society.” This point is often echoed by those reflecting on the ethical
principles and virtues of professionals in general (Bellah et al 1985;
Camenisch 1983; Doherty 1995; W.E.May 1984; Meara et al. 1996). As I
have documented, psychotherapists tend to be deeply individualistic,
focusing on clients rather than on the general welfare. Social
responsibility has been the subdued note in recent professional ethics
(Sullivan 1995).
Although the well-being of clients and the well-being of a society are
often coterminous, conflicts occur. As Kultgen points out, “Sometimes
service to patrons does indeed redound to the public good…. But
sometimes it does not. Patron loyalty takes priority over public interest.
This pollutes the stream of professional practice at its spring” (Kultgen
1988:4).
Conflicts between client well-being and societal well-being take a
variety of forms. Pursuing the well-being of individual clients can lead to
societal harm, and aiming for the general welfare can harm individual
clients. Doherty argues, for instance, that a crisis in public confidence in
therapists has developed in the US because of therapists’ inability “to
speak to the profound social and moral problems of our day” (Doherty
1995:3). In asking, “Are therapists making these problems worse by
justifying the contemporary flight from personal responsibility, moral
accountability, and participatory community?” (ibid.), Doherty voices the
concerns of many social critics about dominant American forms of
psychotherapy. Sarason warns against those who emphasize the public
interest in ways that equate public interest with the “individual and
professional self-interest” of psychotherapists (Sarason 1986:904). A
different type of conflict, M.A. Hall (1997) argues, arises when
professionals are expected to benefit a society by having them make
decisions about health expenditures. Doing so, he asserts, compromises a
central principle of professional ethics: client well-being is paramount.
PROFESSION AND PROFESSIONAL ETHICS 249
That is, misplaced professional concern for societal well-being can harm
clients.
Balancing the twin obligations of professional ethics—to client and to
society—can be accomplished in a variety of ways. Promoting individual
well-being in ways that benefit society is an obvious solution, one
articulated with sensitivity to client autonomy by Cushman (1995),
Doherty (1995), and Gerber (1992). If three forms of therapy benefit
individual clients equally—with one harming society, the second neutral,
and the third benefiting society—the first is likely to be wrong, the third
likely to be best. A second way to balance the professional’s twin
obligations is to develop goals for therapy through public philosophies
and social contracts that involve all therapy stakeholders. Koocher (1994)
and Veatch (1989a) suggest another approach: laypeople and
professionals working together to develop codes of professional ethics
emphasizing social responsibility and the public interest. May argues for
an approach to being professional in which “professional privilege and
loyalty to client are important but must be balanced against other societal
norms” (L.May 1996:7), an approach stressing the common good
(embracing a plurality of goods) and autonomy. And Sullivan argues for
revitalizing the tradition of civic professionalism so the professional takes
“responsibility through one’s work for ends of social importance”
(Sullivan 1995:xvi).
Although they are likely components of a comprehensive solution,
those proposals will not entirely eliminate the tension arising from the
professional’s dual allegiance to societal and client well-being. Conflict
will continue because therapists, clients, and third-party payers disagree
about the nature of the general welfare and the optimal way to balance the
good of societies and individuals, because practices benefiting society
sometimes harm individuals, and because practices benefiting
individuals sometimes harm societies.
Therapists’ ethical influence on clients
“Most clients come” to insight-oriented therapists, London (1986:48)
avers, “for simple cure, not knowing they may take home moral counsel.”
Professional ethics is relevant to such moral counsel, and to other ethical
dimensions of therapy. But because the ethical character of therapy is
more extensive and pervasive than once believed, rethinking how codes
of ethics apply to therapy is essential. We need careful thinking about
professional ethics in relationship to several ethical dimensions of
therapy: conflicts between the ethical convictions of therapist and client,
the empirical finding that clients sometimes adopt their therapists’ values
(Bergin 1991; Beutler and Bergan 1991; Kelly 1990), conflicts between the
ethical convictions of therapists and third-party payers, differing therapy
goals, the implicit nature of many ethical issues, ethical differences across
cultural, subcultural, and religious ethical communities, and deep ethical
250 ETHICS AND VALUES IN PSYCHOTHERAPY
diversity. I want to address those issues by considering two questions:
how do therapists address therapy’s ethical dimensions in accord with
professional ethics? and, given therapy’s pervasively ethical character,
how can we best rethink professional ethics?
Unethical ways to handle ethical issues in therapy, discussed in
connection with therapy process in Chapter 8 and ethical diversity in
Chapter 10, are easily spelled out. Therapists ought neither impose their
ethical convictions on clients nor claim complete value-freedom.
Unethically eliminating or reducing client freedom can occur in several
ways: therapists being judgmental, claiming (or implying) that clients can
only improve by adopting their therapist therapist’s ethical position,2 or
addressing ethical issues in a biased manner.3 In addition to abridging
client freedom, those influence processes may result in harm to clients.
Violations of professional ethics also occur when therapists fail to
provide clients with adequate information about the ethical character of
therapy, violate the explicit or implicit terms of therapeutic contracts
(especially when promises of ethical neutrality are made that cannot be
kept), and lack the ethical competence to address ethical issues in therapy
(Tjeltveit 1986). Indeed, argues Wallace, those who hold therapy “as a
potentially adequate morality and Weltanschauung” are guilty of
“medical imperialism in the worse sense of the word” (Wallace 1991:113),
a charge relevant to those who claim therapists not only do function as
priests but should embrace that role.
A variety of positive proposals for handling general ethical issues in
therapy has been set forth. These approaches to the ethical character of
therapy overlap and often can (and perhaps should) complement one
another. Indeed, overly simplistic “solutions” often cause as many
problems as they solve. I will discuss, in turn, proposals that emphasize:
principles and virtues of professional ethics, providing adequate
information about therapy to other therapy stakeholders, dialogue
among therapy stakeholders, developing and honoring agreements about
therapy, and the nature of appropriate ethical influence. After stressing
the practical wisdom necessary to balance those considerations in the
contexts of concrete therapeutic relationships and in specific societies, I
will address the need for greater awareness and more extensive
education among therapy stakeholders. After reviewing some limits of
professional ethics, I will revisit why—at a more fundamental level—
professions and professionals affirm professional ethics, because answers
at those theoretical and motivational levels can overcome some of the
shortcomings of consensually developed, minimalist professional ethics,
and also improve therapy’s ethical character. I will address the final
proposal in Chapter 12—developing the best possible answers to the full
range of ethical questions addressed in therapy.
Principles of professional ethics delineated by Meara, Schmidt, and
Day (1996) include respect for autonomy, nonmaleficence, beneficence,
justice, fidelity, and veracity. Therapists addressing ethical issues with
clients should thus, for example, preserve and enhance client autonomy
PROFESSION AND PROFESSIONAL ETHICS 251
and seek to benefit them. This may mean working within a client’s
ethical framework (unless there are compelling reasons not to do so—like
harm to the client or others) and matching clients with therapists who
have similar ethical perspectives. When deep ethical differences divide
therapist and client, referring clients to like-minded therapists may be in
order (Odell and Stewart 1993). A therapist who despises Anna’s
religion, for example, should refer her to a therapist who can work
effectively with her. And a religious therapist who despises a prospective
client’s ethical convictions should also refer. Making such referrals
(matching therapist and clients on the dimension of ethical convictions) is
consistent with the ethical principles of respect for client autonomy and
beneficence.
Virtues befitting the role and calling of the professional therapist are
also relevant, for instance, Doherty’s (1995) caring, courage, and
prudence. Therapists who genuinely and consistently care for clients
will, for example, be more likely than therapists lacking that virtue to
address ethical issues in therapy in a manner consistent with the highest
standards of professional ethics.
Information about therapy, including information about its ethical
character, generally benefits clients, therapists, and other therapy
stakeholders. And so, in the absence of compelling reasons to withhold it,
information is to be shared freely and explicitly. “It is essential,” Bergin
argues, “to be explicit about this valuational process [of therapy] because
it always occurs, but often unwittingly” (Bergin 1991:396–7). Feminist
therapists (Feminist Therapy Institute 1990) and radical psychologists
(D.R.Fox 1993), members of distinctive ethical communities, also stress
providing explicit information. Therapy clients may particularly profit
from information about the ethical dimensions of therapy, including
potential ethical conflicts with therapists and the possibility of clients
being converted to their therapists’ ethical convictions. In addition,
therapists and clients would benefit from clear information from thirdparty payers about the circumstances under which therapy will and will
not be reimbursed and about the ethical convictions underlying the
decisions of third-party payers. Unfortunately, some third-party payers,
in accord with their business ethics, may withhold information as a
“business secret.”
The importance of a dialogue among therapy stakeholders about
therapy goals and processes is often stressed. The ideal: therapists,
clients, and third-party payers, all functioning as ethicists, conduct
conversations from which clear expectations and goals develop. Such
collaboration (Bergin 1991) can contribute to a positive therapeutic
outcome, an outcome sought by clients and other stakeholders.
Whatever its merits in general, however, dialogue is sometimes
contraindicated. When clients are psychologically vulnerable, a sustained
dialogue about emotionally loaded ethical topics may harm clients, in
violation of the principle of nonmaleficence. In that situation, a therapist
appropriately forgoes dialogue (although dialogue respects autonomy) to
252 ETHICS AND VALUES IN PSYCHOTHERAPY
benefit the client. Beneficence, respect for autonomy, and nonmaleficence
thus need to be balanced.
Agreements about the nature and goals of therapy, which may arise out
of such dialogues, play an important role in addressing ethical issues
ethically. Clients clear about the nature of a therapeutic relationship can
give informed consent to it (Braaten et al. 1993; Dyer and Bloch 1987;
Faden and Beauchamp 1986; Lidz et al. 1984; Tjeltveit 1986). With clear
information, therapists and clients can also give informed consent to a
relationship with a third-party payer. And social contracts concerning
therapy can be developed. Although, as noted in Chapter 8, completely
informed consent is sometimes neither possible nor desirable (clients may
be incapable of grasping information about therapy or giving consent,
short-term therapy may permit little time to provide full information
about therapy, and clients may be more concerned about feeling better
than about the remote possibility of an ethical side-effect of therapy),
when feasible and to the extent possible, clients should begin therapy
agreeing with the therapist (and third-party payer, if possible) about its
goals and nature. Once an agreement is established (and implicit
therapeutic contracts, based on cultural and client understandings of
therapy, can be assumed where explicit discussion does not occur),
therapists should honor the agreement.
Therapists and clients can, in some circumstances, negotiate nonstandard agreements about therapy. A therapist and client who want to
address ethical issues primarily or exclusively can do so. But careful
discussions need to precede such a change in roles. Unless the third-party
payer concurs with the new agreement, reimbursement should not be
sought. In accord with another relevant ethical principle, therapists are
ethically bound to limit their practice to their areas of competence, to
practices for which they have been trained. And so, a therapeutic
relationship focusing on ethical issues, especially when unrelated to
psychological problems, should occur only when the professional has
demonstrated competence to address those issues.
Finally, the type of ethical influence which therapists exert on clients
has received sustained attention, with some forms of influence viewed as
ideal and others unethical. Therapists disagree about the proper scope of
therapeutic influence. Proposed solutions parallel those discussed in
Chapter 10 to address ethical diversity. Some argue for an ethical
influence that is limited to a narrowly delineated role. Others emphasize
therapist influence on ethical issues about which there is consensus.
(Those, like Anna, who hold minority ethical views may not want
therapists to alter those views, however.) Finally, others support ethical
influence in accord with particular ethical communities, with an ethic for
moral strangers, or both.
Therapists appropriately influence clients in a variety of ways.
Doherty’s (1995) eight-fold spectrum of ethical influence strategies, for
instance, respects client autonomy, makes no claims to be ethically
neutral, and requires therapist sensitivity and clinical acumen. As
discussed in Chapter 8, therapists can address ethical issues without
PROFESSION AND PROFESSIONAL ETHICS 253
attempting to alter clients’ ethical views—by consulting, teaching, acting
as midwife, clarifying, engaging in dialogue, and correcting cognitive
errors (Meehl 1981).
Minimizing therapist influence on the ethical dimensions of clients’
lives is a proposal which many (e.g. Michels 1991) think that professional
ethics requires. Therapists who want to limit their influence to the arena
of their professional competence strive to minimize their influence on
client ethical convictions. Although many advocates of this proposed
solution recognize that complete value-freedom is impossible, they urge
therapists to restrict their persuasive influence to ethical convictions
consensually tied to the goal of mental health. However, the fact that any
concept of mental health (including concepts of mental health
consensually affirmed by most therapists) is tied to ethical assumptions—
assumptions that some clients do not endorse—means therapists need to
work very carefully with those holding minority ethical viewpoints.
Indeed, legitimating therapist influence on mental health values may
result in therapists inappropriately influencing clients to adopt a society’s
dominant values (tied to its understanding of “mental health"). The
existence of ethical diversity thus places a burden of proof on those who
attempt to influence ethical views not included in therapist—client
contracts.
Ethical diversity also suggests the importance of another concept
discussed in Chapter 10: professional ethics functions as an ethic for
working with “moral strangers.” Respect for others, minimizing ethical
influence, and valuing the person’s autonomy are essential. Because
content-less, however, such an ethic provides no guidance to therapists
who want to establish optimal therapeutic goals. Therapy with clients
lacking clear goals thus tends to be shaped by implicit therapist or
cultural ethical convictions. Or to drift aimlessly.
The content-full supplement to an ethics for moral strangers is this:
therapists may influence client ethical convictions in accord with the
ethical views of a particular ethical community. Doherty (1995) and
Cushman (1995) do so, for instance. They encourage clients to consider
their progressive political agendas, as do feminist therapists and
therapists from particular religious communities. This, again, is
appropriate only when client autonomy is preserved, clinical sensitivity
employed, and informed consent obtained.
As noted above, I think that each proposal has merit in some ethical
situations. To balance those, to know which is best with a given client at a
given point in a therapeutic relationship in a given culture at a particular
point in history, is sometimes extraordinarily difficult. No general
answers, applicable always, are available. Therapists need, rather, the
virtue of practical wisdom. Therapists possessing that kind of wisdom
know how to think about a given situation and come up with the best
possible ethical solution. They have a good sense of timing, tailor ethical
influence to meet the specific needs of particular clients (Doherty 1995),
and possess ethical expertise. Caplan argues that:
254 ETHICS AND VALUES IN PSYCHOTHERAPY
expertise in both science and ethics appears to consist in part of
knowing not only what theory or theories are defensible, or which
moral traditions or paradigms are most defensible, but in how to
pick and choose among theories and traditions to provide
appropriate answers to specific problems or problematics. It should
go without saying that expertise also consists of knowing when
theory and tradition have nothing to offer.
(Caplan 1989:81)
Practical ethical wisdom can be developed, aided by education, dialogue
with other therapists and with those who are ethically sensitive, and
greater awareness. Therapists choosing to become wiser learn about their
own ethical views, the views of clients, and the full range of ethical
dimensions of therapy, including ethical assumptions that are implicit
and that are tied to culture.
Awareness of the ethical character of psychotherapy is a prerequisite
for most of the proposed solutions that I have just discussed. Parloff,
Goldstein, and Iflund argued, for instance, that “the therapist must be
aware of his {or her} own values” (Parloff et al. 1960:300). To avoid
imposing my values on others, I must know what my values are. Optimal
awareness extends far beyond awareness of values, however. “Values”
carries many connotations and many ethical dimensions of therapy are
not well captured by that language. Awareness of those other ethical
dimensions is important as well. To put the matter more simply, the
responsible professional possesses a sophisticated ethical understanding.
Although some awareness comes through self-reflection (e.g.
awareness of what an individual thinks and feels about specific issues,
such as abortion), other forms of self-reflection require more concentrated
educational efforts because the ethical character of therapy is by no
means limited to values (understood as feelings or beliefs originated from
within a person). Three levels of awareness regarding the ethical character
of therapy are necessary: awareness of the therapist’s own answers to
ethical questions, awareness of the ethical character of therapy qua
therapy (including its cultural location and a society’s assumptions about
therapy), and awareness of clients’ answers to ethical questions. Pedersen
and Marsella, for instance, argued that it is “the ethical responsibility of
counselors and therapists to know their client’s cultural values before
delivering mental health services” (Pedersen and Marsella 1982:492).
A full-fledged understanding of the ethical character of therapy is multidimensional: values need to be understood in psychological and ethical
terms (as in the educational program implemented by Vachon and
Agresti 1992), but also in terms of power. Awareness of professional
ethics can be supplemented by theoretical ethics (including the full range
of ethical theories), cultural ethics, social ethics, and clinical ethics. The
ethical principles held by therapists and clients, and implied logically by
therapy theories and procedures, can be addressed, along with the
PROFESSION AND PROFESSIONAL ETHICS 255
virtues possessed by, and aspired to, professionals and clients. Of
particular importance is therapist awareness of the relationship between
ideas about ideal psychological functioning (mental health) and other
ethical ideals, because therapists who change the ethical convictions of
clients often justify doing so by falsely assuming that psychological
problems can only be overcome when clients adopt the ethical
convictions of therapists. Knowledge of cultural, subcultural, and
familial ethical convictions is often needed in order to understand clients
and to work with them ethically and effectively. Finally, the vital sources—
psychological, cultural, and intellectual—of the ethical dimensions of
therapy stakeholders can be explored. To summarize, for therapists to be
fully aware of the ethical character of psychotherapy, they need
education about, and awareness of, the full range of ethical dimensions of
therapy addressed in this book.
To optimally address the ethical character of psychotherapy requires an
awareness of the shortcomings of professional ethics. Codes of
professional ethics make important, but ultimately modest, contributions
to therapists addressing the ethical character of psychotherapy. Although
professional associations set up rules, procedures, and bureaucracies to
ensure the actions of professionals conform to professional norms,
“bureaucracy,” as Taylor notes, “creates its own injustices and exclusions
and…a great deal of suffering is not so much relieved as rendered
invisible by it” (Taylor 1989: 398). Bersoff raised another critique: the
current American Psychological Association (1992) ethics code is too
concerned about the well-being of psychology. The code, he suggests, is
“anachronistic, conservative, protective of its members, the product of
political compromise, restricted in its scope, and too often unable to
provide clear-cut solutions to ambiguous professional predicaments”
(Bersoff 1994:385). The minimalist code, he suggests, “builds an ethical
floor but hardly urges us to reach for the ceiling.” Reaching for the ceiling
would surely entail what May urges: greater attention to professionals’
“public obligation” (W.F.May 1984:259).
Finally, codes of ethics usually include neither psychological nor
theoretical rationales for individuals embracing them, or embracing any
other ethical ideal. “Professional ethics codes cannot,” Kitchener (1996a:
369) notes, “act as a conscience.” And others argue that “because the
Ethics Code does not argue or cite evidence but rather simply asserts, it
provides no acceptable warrant for its assertions” (O’Donohue and
Mangold 1996:377). Codes of professional ethics are thus, to borrow
language from Chapter 10, too thin, too content-less to nourish
professionals. To sustain psychotherapy, professionals need a thicker
ethical gruel, need reasons as professionals and as individuals to engage
in the ethical actions and the reflection that are integral to the professional
psychotherapist.
256 ETHICS AND VALUES IN PSYCHOTHERAPY
Why professional ethics?
In the absence of compelling reasons—compelling psychological reasons
and compelling intellectual reasons—psychotherapists in the future may
no longer affirm a profession’s ethical standards. Those standards face a
variety of severe challenges: skeptical questioning about “self-serving”
professionals, ethical relativism (including relativistic versions of multiculturalism and skeptical postmodernism), a retreat to the “objectivity”
of science, and businesses that treat psychotherapists as mere “providers”
of the business commodity labeled psychotherapy. Identifying why
professions and professionals endorse professional ethical principles is
thus vitally important.
Skeptics argue that professionals endorse minimal standards of
professional ethics for purely pragmatic reasons: to obtain prestige,
payment, and autonomy for professionals. Critics from within a
profession sometimes criticize codes as well. The American Psychological
Association’s (1992) code, for example, has been criticized for its
cautiousness (Bersoff 1994), for being based “on the unvalidated opinions
and beliefs of well-intentioned colleagues with severely restricted vision”
(Koocher 1994:361), and for failing to articulate the ethical grounds on
which it is based (O’Donohue and Mangold 1996). Indeed, O’Donohue
and Mangold assert that the code “provides no acceptable warrant for its
assertions. Epistemologically its acceptance relies upon an authoritarian
appeal (Because the APA says so!) rather than upon an epistemology that
recognizes the importance of defending one’s claims by arguments”
(ibid.: 377).
The existence of carefully delineated, lawyer-vetted rules and
procedures for professional ethics committees (e.g. Ethics Committee
1996) may protect psychologists (and professional associations like the
APA) from unwarranted lawsuits, ensure procedural justice for those
accused of ethical violations, and sanction professionals who are found
guilty of violating an ethics code. But because few people give their
allegiance to bureaucracies, rules, and procedures, I suspect codes and
committees inspire many psychologists to practice in a manner best
characterized, not as optimally ethical, but as cautious and self-protective.
The ethical minimalism endorsed by most codes of professional ethics
(and much contemporary philosophy) produces another problem.
Because “we have no theory of the common good,” May argues,
“professionals feel relatively free to direct…power to their own ends”
(W.F.May 1984:259).
But developing an ethics code that aims for the ethical ceiling rather
than towards establishing a minimally acceptable ethical floor (Bersoff
1994) is made very difficult by the neo-Nietzschean skeptical
postmodernist attack on beneficence, by the deep ethical differences that
divide many societies, and by other developments, including
individualism and the assumption that human behavior is motivated
selfishly (Wallach and Wallach 1983). In the absence of agreement about
PROFESSION AND PROFESSIONAL ETHICS 257
ethical theory in a society, it is profoundly difficult to follow the
recommendation that “the ethical grounds of the code be explicated and
defended” (O’Donohue and Mangold 1996:376).
The absence of a compelling intellectual rationale for a profession’s
code of ethics is a major problem. If, as I have argued, professionalism—
tied inextricably to beneficence and other ethical principles—is integral to
what it means to be a psychotherapist, but the professions of
psychotherapy can give no compelling reasons for affirming their ethical
core, those professions are incoherent.
Given ethical diversity and the aspiration that therapy should be a
universal, cross-culturally valid type of helping relationship, codes of
professional ethics are necessarily built on consensus. A minimalist ethics
results, one asking that therapists treat “moral strangers” justly and with
respect. Although such consensual standards are important, most people
do not live by ethical standards so minimal, so thin. In fact, many (most?)
psychotherapists who practice ethically draw upon deeper ethical sources
—deeper psychological sources and deeper intellectual sources. And so,
while mandating a common core of minimal standards, professional
ethics should endorse diversity regarding ethical issues falling outside
the consensus, including such key issues as the reasons therapists
endorse professional ethical standards, the nature of the common good,
and ideal human functioning.
If professional codes of conduct cannot, as Kitchener rightly avers,
function “as a conscience” for the psychotherapist, what will?
“Ultimately,” she notes, “the well-being of those with whom
psychologists work will depend on how seriously psychologists take
their ethical responsibility to treat others with care” (Kitchener 1996a:
369). Because consensual ethical standards are inadequate, professionals
need to turn to deeper levels of ethics. Professionals need to draw upon
local ethical communities, upon particular sets of ethical convictions that
motivate and provide intellectual stimulation to therapists, that motivate
them to practice as ethically as possible. They need to turn, that is, to why
individual professionals and particular ethical communities affirm
professional ethics and other types of ethical principles and virtues.
Manifold reasons lead communities (including professions) to take
seriously ethical principles and virtues, including sources deeply
interwoven into the fabric of Western thought (Taylor 1989) and in the
thought of other cultures. But the curious reluctance to acknowledge and
articulate moral sources in the West (Taylor 1989) and the failure of
rational procedures to justify ethical claims (MacIntyre 1984) make it
difficult to reflect on and articulate ethical sources. Taylor observed that
benevolence has continued to be important in the West, although
Westerners find it difficult to articulate why it should be so. But he asks
an important question, vitally important for undergirding the ethical core
of the professions: “What can sustain this continuing drive?” (Taylor
1989:398).
Individual therapists practice ethically for a variety of reasons,
including some self-serving reasons: social pressure, legal consequences,
258 ETHICS AND VALUES IN PSYCHOTHERAPY
public relations, and enlightened self-interest. But there are other
reasons, intellectual reasons and psychological reasons. Many
psychotherapists can articulate the reasons for their convictions about
what is good, right, and virtuous, reasons not derived entirely from
science and reason, reasons not shared by everyone (or even the
majority) within a society or a profession. Those therapists affirm
professional ethics for particular ethical reasons. Other therapists,
wanting better ethical answers, unclear of their ethical convictions, or
both, seek out ethical dialogue and greater ethical articulacy.
Psychological reasons, growing out of an individual’s moral
development, cognitions, learning history, motivation, intuitions,
emotions (e.g. caring), and character traits (virtues), play a role in
therapists practicing ethically. Ethical action stems from ethical persons.
Because professionals sometimes act in ways that do not benefit
themselves, the source of their beneficence must involve powerful
psychological forces. As Taylor notes, “high standards need strong
sources” (Taylor 1989:516). Professionals act to benefit others, not simply
for selfish reasons but because they genuinely believe it good and right so
to do, because they draw on fertile ethical sources.
I will revisit those deeper, more fundamental sources of the
professional’s ethical convictions and behaviors in Chapter 12. Individual
(and community) sources—both intellectual and psychological—can give
rise to the professional ethics that characterizes the professions conducting
psychotherapy.
12
Shaping the ethical character of
psychotherapy
Inevitable choices, better choices
The ethical character of psychotherapy—largely implicit, created and
sustained by myriad cultural, intellectual, and practical threads that are
woven into the fabric of the sciences and the professions, into the economic
structures of therapy, and into contemporary images of therapy—is, in
part, beyond the control of therapists, clients, third-party payers, and
other therapy stakeholders. But only in part.
In this chapter, I want to address how therapy stakeholders can make
better choices that influence the ethical dimensions of therapy. I want,
that is, to address how therapists and other stakeholders can shape the
ethical character of therapy, can make the inevitable ethical choices
therapy entails, can make better choices.
Choosing in accord with professional ethics
Psychotherapists who choose to become professionals choose to limit the
ethical character of the psychotherapy they provide. They limit therapy
within bounds set by professional ethical standards, and constrain
themselves ethically in ways other therapy stakeholders need not.
Professional ethics restricts psychotherapists to certain forms of
therapy process and (to a lesser extent) to a certain range of therapy goals.
The ethical principle of beneficence shapes the ethical character of
therapy in a crucial manner: therapy goals should, in some way, benefit
clients and/or a society, and not the therapist alone. Because clients and
societies can benefit from therapy in many ways, and alternative ethical
positions define “benefit” in different ways, beneficence permits ample
ethical freedom to therapists. Beneficence does, however, place some
limits on the goals which therapists legitimately pursue.
Principles of professional ethics constrain therapy processes by shaping
the nature and quality of therapists’ interactions with clients. Therapists
are to treat clients with respect, to uphold and enhance client autonomy,
to maintain confidentiality, to provide services only when competent to
do so, to provide therapy in accord with the therapeutic contract, not to
exploit clients sexually, and so forth. Codes of professional ethics thus
260 ETHICS AND VALUES IN PSYCHOTHERAPY
serve as a form of ethics for moral strangers (Engelhardt 1991), one which
professionals, by virtue of being professionals, agree to endorse.
Codes of professional ethics provide crucial, but ultimately modest,
restraints on therapists’ ethical choices. They do not provide reasons for
therapists to affirm and live by professional ethical ideals. Lacking an
intellectual and psychological rationale to affirm professional ethics,
some professionals rely simply on professional consensus and
enlightened self-interest. Consensus and self-interest are often
insufficient, however, to motivate therapists to reach the highest ethical
levels of practice. Indeed, codes tend to establish an ethical minimum,
rather than helping therapists to identify, and practice in accord with, the
highest possible ethical standards (Bersoff 1994). Professional codes of
ethics are, as noted in Chapter 11, too thin, too intellectually and
psychologically restrained, and too general to equip therapists to address
the full range of ethical issues raised in therapy. Finally, professional
ethics bind therapists, but not the other partners in therapeutic
endeavors, the clients and the silent partners (third-party payers,
taxpayers, corporations, pensioners, and others) for whom
psychotherapy is important. And so professional ethics makes but a
modest contribution to vigorous efforts to identify the best therapy
values, specify ideal goals for clients, and to articulate the optimal role of
psychotherapy in a society.
The challenge of improvement
In light of the limits of professional ethics and the reality of an ethical
diversity that makes it difficult, if not impossible, to achieve substantive,
content-full ethical consensus, how can the ethical character of therapy be
shaped?
Conservative voices may argue there is no need to do so: “The ethical
character of psychotherapy is just fine, thank you.” They argue for the
goodness of therapy’s existing values, the impossibility of improvement,
or both.
As we have seen, however, critics pose penetrating questions about the
ways in which many therapists currently address therapy therapy’s
ethical dimensions. In considering therapy’s influence on society, for
instance, Bellah, Madsen, Sullivan, Swidler, and Tipton (1985) wonder,
for instance, whether “psychological sophistication has not been bought
at the price of moral impoverishment” (Bellah et al. 1985:139). They and
others call for ethical improvement. They contend that therapists who
address ethical issues (i.e. all therapists) can become better ethicists. And
that all therapy stakeholders can choose better, richer ethical perspectives
—to the benefit of therapy clients and society.
Can we make ethical progress?
“No!” assert skeptical postmodernists and advocates of logical
positivist ethical theory, curious allies in opposition to careful ethical
reflection. They echo what was once commonly accepted wisdom among
SHAPING THE ETHICAL CHARACTER OF PSYCHOTHERAPY 261
therapists: the goal is psychotherapy that is value-free, objective, ethically
neutral. When ethics needs to be involved at all, therapists were taught
they ought to stick to professional codes of ethics, or to their society
society’s consensual values. Or, if unable to do that fully, to minimize
their influence on client ethical convictions.
But a growing number of voices is challenging that received wisdom,
arguing that it would be good for therapists and other stakeholders to
think carefully about the ethical character of therapy and to improve the
ethical character of therapy. The challenge, asserts Doherty, is “to take a
step beyond critique into reenvisioning psychotherapy as a moral
enterprise” (Doherty 1995:14). The issue, finally, is not whether we can
conduct value-free therapy. We cannot. The issue is identifying those
values, those ethical convictions, best included in particular therapy
sessions and in therapy sessions in general. Beutler, for example,
suggested that we may need to question “whether there are some values
that may be more important for a therapist to accept than others” (Beutler
1978:63). Drane suggested that “one has to be only a moderate
rationalist” to believe that psychiatry’s influence on “the ethical quality
of human life…would be improved by a more thoughtful, studious,
prudent, and methodical approach” (Drane 1991:58). Likewise, Smith
argued that psychologists “can do much better than is usual for us by
trying…to emphasize informed, rational, disinterested, benevolent
decision making” (M.B.Smith 1990:533). And philosopher of science
Laudan noted, “I suspect we all believe that some cognitive ends are
preferable to others” (Laudan 1987:29).
Taylor (1989) argues for the appropriateness of employing the “best
account” we can develop. Developing a best account, he argues, requires
practical reasoning. Rather than identifying some rational method by
which we allegedly arrive at “certain” ethical conclusions, we compare a
proposed new answer with our existing answer (or confusion). We accept
the new ethical idea only if better than our existing idea. Such reasoning,
Taylor argues, “aims to establish, not that some position is correct
absolutely, but rather that some position is superior to some other”
(Taylor 1989:72).
Those authors share the courage to assert that one ethical position is
better than another, but without claiming that that ethical position is
“certain,” “indubitable,” “infallible,” “self-evident,” “absolute,” or
“perfect.” They make ethical assertions without descending into
authoritarianism. “There is a big difference,” notes Prilleltensky (1997:
518), “between searching for the best moral option under a particular set
of circumstances and the pursuit of a dogmatic set of rules.” Similarly, we
can arrive at “valid substantive ethical insights, even if they are never
final or certain” (Richardson and Woolfolk 1994:222).
In this chapter I want to explore how we can develop better ethical
accounts of the full range of ethical issues in therapy. Given the
ethical assumptions of many modernists (MacIntyre 1984), identifying
therapy processes that are ethically better than others is less controversial
than identifying better therapy outcomes. Even the logical positivist may
262 ETHICS AND VALUES IN PSYCHOTHERAPY
agree that a therapy technique whose efficacy is empirically supported is
better (more ethically justified) than a technique that empirical evidence
suggests is ineffective or harmful. Likewise, even skeptical
postmodernists might think that some forms of therapy are superior to
others. For example, forms of therapy conducted by therapists who do not
delude themselves (are unflinchingly honest) about their ethical ideals
and their power over clients, and that promote the emancipation of
clients, may be considered superior to therapy conducted by therapists
who deny ethically influencing clients but, in fact, impose on clients their
moral views.
Better ethical accounts of the goals or outcomes of therapy can also, I
believe, be developed. For example, suppose a given therapy case has four
possible outcomes: the client benefits but society is harmed, society
benefits but the client is harmed, both the client and society are harmed,
and both the client and society benefit. The final alternative is, I think,
clearly best. A central purpose of therapy is to benefit clients. And a wide
range of ethical theories and codes of professional ethics argue for the
goodness of advancing the general welfare (cf. Garrison 1997; Gerber
1992; Sarason 1993). As I have documented above, many therapists and
others are now arguing for forms of therapy that accomplish both aims.
Mahoney, for instance, states: “I believe that the helping professions
must address issues that link our individual lives and our collective
responsibilities” (Mahoney 1991:4). On those ethical accounts, then, some
therapy outcomes are better than others.
Disputes about the proper balance in therapy of client and societal
well-being will, I suspect, be with us always. As will other ethical
controversies, such as the goodness of other therapy goals and the
optimal role of therapy in a society. But my claim is not that we can solve
all ethical problems (and definitely not that we can solve them with full
rational certainty). Rather, my claim is that, when addressing the ethical
character of psychotherapy, including therapy goals, we can sometimes
develop better ethical answers. And so we should try.
Making better choices about the ethical character of
psychotherapy
Some approaches to addressing ethical issues will, I believe, help therapy
stakeholders make better choices about the ethical character of therapy,
choices that undergird therapists’ commitments to professional ethics,
that shed light on the qualities of the ideal therapist-client relationship,
and that provide insight into good (or better) therapy goals. These
approaches may also lead to the wisdom that London suggests therapists
should seek: “Suppose [therapists] make a virtue of necessity and ask
themselves how, since their technical capacities imply a moral role
anyway, they could exercise that role most wisely” (London 1986:152–3).
In this concluding section, I set forth, with broad brush, some ways I
SHAPING THE ETHICAL CHARACTER OF PSYCHOTHERAPY 263
think therapists (and other therapy stakeholders) can exercise that ethical
role wisely.
Ethical acuity
Therapy stakeholders who see with clarity ethical issues relevant to
psychotherapy, and who see with clarity viable ethical alternatives, will
tend to make ethical choices that are better than those whose ethical
vision is occluded or distorted. Unless a person perceives with accuracy
key ethical dimensions of a situation, unless a person faced with an
ethical decision “‘sizes up,’ or construes ethically salient features of a
situation” (Punzo 1996:12), he or she will not make optimal ethical
decisions. And without ethical acuity, people will not develop better
ethical accounts of therapy.
People vary in their sensitivity to ethical issues and to the
consequences of alternative actions (Rest 1984). Education can produce
positive changes in that and other ethical skills (Rest 1988). And so
people can improve their clarity of ethical vision.
Ethical acuity can improve, I believe, when people approach ethical
issues in a balanced way, increase their knowledge of ethical alternatives,
develop their ability to think ethically, and pursue the other suggestions I
make in the remainder of this chapter. That enhanced ethical
perceptiveness will, in turn, contribute to their ability to carry out those
suggestions. And that, in turn, will contribute to improved ethical
decisions about the ethical character of therapy.
Balance
Ethical approaches that balance, or hold in tension, more than one
approach to the ethical character of therapy are better than those that
oversimplify. They are better, for example, than ethical perspectives that
promise easy answers or espouse one principle or ideal as the solution to
all ethical problems. Although optimal ethical solutions to particular
problems are sometimes simple, adequate ethical solutions to the full
range of ethical issues that arise in therapy in general should draw upon
a variety of (often complementary) ideals (Prilleltensky 1997), ideals that
are, in concert, complex and tension-filled. Therapy stakeholders need to
seek, and seek again, an optimal balance among approaches to ethical
questions, avoiding answers that are in some way unbalanced.
When one ethical ideal acquires undue weight, unbalanced therapy
outcomes can result. For example, some therapists focus solely on
individual well-being and so pathologize those who devote time and
energy to causes outside themselves. Doherty (1995) tells of a social
activist who was repeat edly informed by his (liberal!) friends and
therapists that “his social activism stems from unfinished personal
264 ETHICS AND VALUES IN PSYCHOTHERAPY
business. When he takes care of his personal business, so the line goes, he
will stop acting out his missionary zeal in the world” (Doherty 1995:99).
The good of resolved personal issues was not balanced by a concern for
justice and societal well-being. Doherty suggests an alternative: therapy
goals that respect (and even encourage) social activism along with the
goal of improved psychological functioning. A balance of concern for
society and individual well-being, he asserts, is a better way to shape the
ethical character of therapy than traditional US individualism.
Valid claims can be made, Taylor (1989) notes, for a diversity of goods.
The central goods that can be discovered through the self—disengaged
reason functioning as ethical source (i.e. the ethical source upon which
many scientists draw), the creative imagination that looks within the self
for ethical inspiration, and the original theistic alternative (coming into a
relationship with God through looking within)1—all shape the modern
identity. In considering these and other ethical positions, he argues that:
the trouble with most of the views that I consider inadequate, and
that I want to define mine in contrast to here, is that their
sympathies are too narrow. They find their way through the
dilemmas of modernity by invalidating some of the crucial goods in
contest…. Not only are these one-sided views invalid, but many of
them are not and cannot be fully, seriously, and unambivalently
held by those who propound them.
(Taylor 1989:503)
Outlooks claiming that we can avoid making difficult ethical decisions
(e.g. decisions “between various kinds of spiritual lobotomy and selfinflicted wounds”) are, Taylor argues, “based on selective blindness”
(ibid.: 520).
Tension can, and perhaps should, exist among the ethical ideals to be
balanced. Taylor notes that although the various goods for which valid
claims can be made “may be in conflict…they don’t refute each other”
(ibid.: 502). Indeed, he argues that “a complex interplay arises in which
each can be at some moment strengthened by the weakness exposed in
the others” (ibid.: 413). And L.Sass notes that Heidegger’s hermeneutic
approach represents a complex balancing of, or, perhaps better, a holding
in tension of, concern for the individual self and the community: “What
he prescribes is neither a straightforward merging with community,
tradition, or nature nor a romantic-heroic expression of separateness and
individuality” (L.A.Sass 1988:260).
Another sort of balancing is also needed, I think, to answer well the
question of how therapists optimally address the ethical character of
therapy. Careful readers may have noticed that I alternately
value therapists who minimize their ethical influence on clients,
therapists who limit their ethical influence to the professional consensus
about mental health values (values that therapists appropriately
SHAPING THE ETHICAL CHARACTER OF PSYCHOTHERAPY 265
influence), and therapists who conduct therapy in concord with
particular ethical communities (they consciously exert ethical influence
on clients, an ethical influence that diverges from the societal or
professional consensus but is consistent with the explicitly stated wishes
of clients who want a form of recovery from psychological problems that
is in harmony with the client’s ethical ideals). Those three alternatives are,
if not in conflict, at least in considerable tension with one another. I
would prefer to think that my partial affirmation of each represents, not
muddleheadedness, but a legitimate valuing of partial solutions to
therapist influence on client values. Any of those alternatives may be
most appropriate in a given situation, and all, I think, should be kept in
tension when formulating the ideal role of therapy in a given society. I
also hold in tension the search for better answers (contra relativism) and
the pragmatic realization that, for the foreseeable future, deeply divergent
ethical affirmations will most likely characterize almost all societies.
Balanced ethical choices also involve more than one level of discourse
about ethical issues. Kurtines, Alvarez, and Azmitia (1990) argue that
debates are most likely to be productive when participants are free to
“move between levels of discourse, including theoretical, practical, and
metatheoretical levels” (Kurtines et al. 1990:294). Doherty (1995), for
example, focuses more on the practical level, the level of concrete therapy
sessions. This book, by contrast, emphasizes theoretical and
metatheoretical issues. Those seeking the best possible ethical account of
the ethical character of therapy will address all three levels. They will also
take into account what Sadler and Hulgus describe as “three core aspects
of the clinical encounter: problems of knowledge, ethics, and pragmatics”
(Sadler and Hulgus 1992: 1315).
Finally, a sole focus on reason, including reasoning about ethical
matters, can produce unbalanced, less-than-ideal ethical results. As Taylor
(1989) notes, several strands of Western thought have argued that reason
can be destructive, that “rational hegemony, rational control, may stifle,
desiccate, repress us” (Taylor 1989:116). And so “we stand in need of
liberation” from reason. I concur with (moderate versions of) those
criticisms and so I think a strictly philosophical approach is inadequate.
The philosophical needs to be joined with the psychological, including
the emotional. On the other hand, some people, those whose lives are
controlled, not by reason, but by unchecked emotions may exhibit another
kind of imbalance: emotion uncontrolled by appropriate rational selfcontrol. Neither “being in touch with my feelings” nor “reason alone” is
optimal. The best approach balances philosophical reflection with a
psychology that is rich and nuanced.
An ethical character for therapy that is intellectually,
psychologically, and culturally rich and nuanced
The best ethical choices are made by people who draw upon rich and
nuanced ethical sources. This means, I believe, sophisticated accounts that
266 ETHICS AND VALUES IN PSYCHOTHERAPY
combine, and do justice to, psychological, philosophical, and cultural
complexities. Scientists devoted to the ideal of simplicity and to the
tradition of the principle of parsimony may find heretical my claim that
the complex is to be preferred to the simple when addressing the ethical
character of therapy. But Occam’s Razor, despite its benefits for science,
serves the ethicist poorly, and especially therapists functioning as
ethicists. Mental health, for example, is best understood as a mixed
medical/psychological/ ethical concept (cf. my argument in Chapter 7).
I believe that simplistic understandings produce neither adequate
understandings of, nor optimal choices regarding, the ethical character of
therapy. Throughout the book I have argued against simplistic
intellectual understandings of ethics. Simplistic psychologies are to be
avoided as well. For example, psychologies that draw upon neither
psychological research nor the experience of clinicians, that ignore both
science and clinical expertise, are unlikely to produce best accounts of
therapy’s ethical character. Some forms of the philosophy of liberal
individualism, for instance, understand human beings to be what some
label “absolutely free” selves (Bellah et al. 1985: 139). That simplistic
psychology leads, they argue, “to the notion of an absolutely empty
relationship. And this empty relationship cannot possibly sustain the
richness and continuity that the therapeutically inclined themselves most
want, just as they want not empty but rich and coherent selves” (ibid.:
139).
Sufficiently rich understandings of human beings do not assume that
the human will alone can produce ethical behavior (Drane 1994). Rather,
we need a multi-faceted psychology. Fortunately, psychologists in the
post-Kohlbergian era (e.g. Kurtines and Gewirtz 1991, 1995) understand
moral development and ethical decisions in increasingly complex
psychological terms. J.R.Rest, for example, identified four components
involved in ethical behavior: individuals “interpret the situation in terms
of how one’s actions affect the welfare of others,” “formulate what a
moral course of action would be,” “select among competing value
outcomes of ideals,” and “execute and implement what one intends to
do” (Rest 1984:20). Virtue ethicists also use a complex, multi-faceted
psychology, including human motivation, emotions, community, and
ethical character (Meara et al. 1996). Ethical habits are emphasized as
well. This is important because many of the deepest ethical convictions
held by therapists are ingrained in their patterns of behavior. As Birch
and Rasmussen point out, much practical moral reasoning is habitual,
involving neither agonizing moral dilemmas between conflicting ethical
ideals nor philosophical explorations of competing ethical theories.
“Indeed, ‘reasoning’ isn’t the most precise term,” they note, “for what is
frequently a reflexive exercise done without conscious deliberation. We
don’t consciously consider whether or not to hold up the clerk and empty
the cash register as we pick up a gallon of milk at the store” (Birch and
Rasmussen 1989:102). Because much of the ethical character of therapy is
of that mundane, unselfconscious psychological character, we need a
SHAPING THE ETHICAL CHARACTER OF PSYCHOTHERAPY 267
psychology that accounts for the habitual character of therapy’s ethical
dimensions, along with accounting for the ethical choices therapy
stakeholders make consciously.
Taylor describes some other ways in which many ethical perspectives
avoid psychological complexity. Important ethical consequences follow,
he argues, when we deny the complexity of what we can learn when we
explore what resonates with our personal experience. “Proponents of
disengaged reason or of subjective fulfilment,” he observes:
embrace those consequences gladly. There are no moral sources
there to explore. Root-and-branch critics of modernity hanker after
the older public orders, and they assimilate personally indexed
visions to mere subjectivism. Stern moralists, too, want to contain this
murky area of the personal, and tend as well to block together all its
manifestations, whether subjectivist or exploratory. Morality is held
to be distinct from all this, independent of it, and imperiously
binding.
(Taylor 1989:512)
Strictly separating the ethical from the psychological, Taylor argues, is an
error committed by some philosophers and theologians. Habermas and
Hare, for instance, claim that the correct rational procedure will produce
ethical knowledge. And some theologians claim we need not consult
human experience because God provides us with fully satisfactory
ethical knowledge. Taylor argues, however, that “a study of the modern
identity ought to make one dissatisfied” with positions that claim we can
ignore the psychological when we address ethical questions (ibid.: 512–
13).
For Taylor, understanding the cultural and historical location of the
rich psychological-philosophical “modern identity” is essential. He thus
joins many others (e.g. Bellah et al. 1991; Cushman 1992, 1995; Doherty
1995) in arguing that a sophisticated understanding of culture and its role
is required to develop a best account of individuals, of the ethical
character of any particular therapeutic relationship, and of the ethical
character of psychotherapy in general. Robinson (Robinson 1997:675), for
instance, discusses the importance of therapists recognizing the
“essentially civic nature” of our humanity.
Increasing awareness of the importance of therapist sensitivity to
clients from other cultures (e.g. Abe-Kim and Takeuchi 1996; Marsella
and White 1982; Minsel et al. 1991; Rodis and Strehorn 1997; S.H.Schwartz
1994), including the religious and spiritual dimensions of culture (e.g.
Browning 1987; Kirschner 1996; W.R.Miller (forthcoming); Richards and
Bergin 1997), is, I think, leading most therapists to a more nuanced, a
better, understanding of the role of culture in therapy. This makes
possible better ethical accounts of therapy. And better ethical choices.
268 ETHICS AND VALUES IN PSYCHOTHERAPY
We can, however, be aware of the ethical character of other cultures
but not of the ethical character of our own culture. This may be especially
true of Western therapists, whose cultural contexts systematically
disguise (and occasionally deny) the ethical character of therapy (see
Chapters 6 and 7). And, as Browning pointed out, when practitioners are
unaware of the cultural context in which they practice, “there is likely to
be an exaggeration of the technical and scientific aspects of care and a
blindness to” the ethical dimensions of “cultural assumptions, symbols
and goals” (Browning 1976: 71). Guignon describes one way (articulated
by Heidegger) in which therapists’ own cultures are relevant to their
ethical understanding:
As we become initiated into the practices of our community, we
soak up the tacit sense of what is important that circulates in our
world. This “attunement” to shared commitments and ideals cannot
be regarded simply as a matter of having certain “life-style options”
on hand for our choice. For these understandings and normative
commitments are definitive for the kinds of people we are. They
provide us with the possibilities of assessment and aspiration that
first give us an orientation toward our own lives and a window
onto the world. Given that we have become the kind of people we
are—people who, for example, care about children and believe in
justice—there is now no way to drop these commitments without
ceasing to be who we are.
(Guignon 1993:233)
The cultural character of contemporary therapy has, fortunately, been
receiving increasing attention (e.g. Cushman 1995; Fancher 1995;
Woolfolk 1998). Rich and nuanced understandings of culture, and of
therapy, result.
Ethical alternatives
To develop better ethical accounts, for the sake of understanding and
making decisions about the ethical character of psychotherapy, therapy
stakeholders can explore alternative ethical approaches, to see which
resonate with their own experience (Taylor 1989), to see which seem most
rationally defensible, to decide which is best. Such an exploration seems
especially important for psychotherapists, who are responsible for
upholding professional ethical standards, to benefit others and not
simply themselves. But a mere sense of obligation to those professional
standards or guilt for failing to uphold them is not enough. As Taylor
points out, “there is something morally corrupting, even dangerous, in
SHAPING THE ETHICAL CHARACTER OF PSYCHOTHERAPY 269
sustaining the demand simply on the feeling of undischarged obligation,
on guilt, or its obverse, self-satisfaction” (Taylor 1989:516).
A wide range of ethical alternatives exists. Traditional alternatives, like
classic liberal individualism and religious ethical perspectives, exist as
live intellectual options alongside more recent proposals, like those
bridging analytic and continental philosophical traditions and those
taking seriously hermeneutic perspectives. The field of ethics in general
and the narrower (but richly interdisciplinary) field of bioethics provide
many resources for ethical reflection. This includes the full range of types
of ethics discussed in Chapters 2 and 4 and elsewhere in this book—
clinical (and applied) ethics, cultural ethics, social ethics, theoretical
ethics, and virtue ethics.
I will set forth, without extensive discussion, a non-exhaustive set of
fourteen alternatives, arranged in alphabetical order. I order them in that
way, not to evade responsibility for categorizing them, but to emphasize
the breadth of alternatives supported by intelligent, thoughtful advocates
and because these ethical alternatives can be categorized in a variety of
ways, all controversial. Various theorists use the same label for varying
approaches, distinguish between ethical alternatives in diverse ways, and
combine approaches that others differentiate. Finally, many subtypes of
each ethical alternative could be set forth, especially within the
hermeneutic, rational, and religious alternatives.
Casuistry, a form of clinical ethics (see Chapter 2), emphasizes the
specific circumstances of a situation along with general ethical principles
when making ethical decisions (Jonsen 1995). Practical, not
metatheoretical, considerations are emphasized.
Classic liberal individualism emphasizes the individual decisionmaker and the ideals of autonomy, justice (e.g. Rawls 1971), and
procedural ethical rules. M.A.Hall (1997) contrasts it with
communitarianism and MacIntyre (1984) with virtue ethics. Classical
liberal individualism is relevant to ethical issues having to do with
therapy process, but because it does not address the goodness of ends
(MacIntyre 1984), it contributes little to (indeed, impedes) ethical
discussions about therapy goals. This ethical tradition has, I suspect,
shaped contemporary psychotherapy more profoundly than any other.
And so therapists find it difficult to engage in ethical discussions about
therapy goals. Furthermore, its individualistic emphasis and the fact that
some of its advocates deny that it is culturally-situated create what has
been described as “a powerful cultural fiction that we not only can, but
must, make up our deepest beliefs in the isolation of our private selves”
(Bellah et al. 1985:65).
Communitarians (Bell 1993; Etzioni 1993, 1995, 1997, 1998; Richardson
and Fowers 1997) suggest that problematic ethical consequences follow
from classic liberal individualism. They argue not only that we can
consider the best ends for a given society, but that we should do so.
Critical psychologists engage in a more fundamental critique of
psychology’s ethical status quo (Braybrooke 1987; Fox and Prilleltensky
270 ETHICS AND VALUES IN PSYCHOTHERAPY
1997; Haan et al. 1985; Keat 1981; Richardson and Woolfolk 1994; E.V.
Sullivan 1984). Often drawing upon Habermas and the Frankfurt School,
critical psychologists argue that we should employ particular normative
perspectives, including ideas about “the way a society should be, the way
it should function, and the way it should be transformed” (Browning
1987: 124). They argue that allegedly “neutral and scientific social science
is impossible and will inevitably be captured by the dominant ideologies
of a particular culture” (ibid.: 124). Critical perspectives, like the other
ethical alternatives I am discussing in this section, can be combined with
other ethical approaches. Kurtines, Alvarez, and Azmitia (1990), for
instance, argue for a “critical co-constructivist” approach. And
Prilleltensky (1997) advocates an “emancipatory communitarianism” that
combines a communitarian approach with the emphasis on autonomy
found in classical liberalism and in critical psychology.
Feminist ethicists (Brown and Ballou 1994; Card 1991; Fox-Genovese
1991; Gartrell 1994; Lerman and Porter 1990; Morawski 1994; Rodis and
Strehorn 1997; Sherwin 1992) argue that we best understand the ethical
character of therapy from the perspective of feminism and feminist ethics.
Hermeneutic perspectives stress the inescapably ethical character of
life, psychology, and psychotherapy (Browning 1987; Fowers 1993;
Messer et al. 1988; Packer 1985a, 1985b; Richardson 1997; Spence 1982).
Drawing upon continental philosophy (especially on the work of
Gadamer, Heidegger, Ricoeur, and Habermas), hermeneuticists do not
strive for explanations in science or ethics that take the form of “general
laws” (Richardson and Woolfolk 1994:212) or nomological explanations.
They strive instead to “interpret the meaning” of human action, including
moral action. Hermeneutic approaches can, Martin and Thompson (1997)
assert, be combined with a neo-realist philosophy of science to create a
psychology that includes, but expands upon, traditional empirical
methodologies.
Narrative is stressed by hermeneutic ethicists and others (e.g. Brody
1994; Guignon 1993; MacIntyre 1984; Richardson and Woolfolk 1994;
L.A.Sass 1988; Taylor 1989; Vitz 1990). They assert that we understand
what is good, right, and/or virtuous through stories. And stories
(including those told by therapists and clients) can have, and perhaps
always have, an ethical dimension.
Naturalistic ethics (also known as sociobiological and evolutionary
ethics) blends a particular set of epistemological, metaphysical, and
ethical convictions (a “moral vision”—Engelhardt and Wildes 1994:142)
with scientific methods and theories to understand ethical issues and
make ethical choices (e.g. Brink 1989; Flanagan 1996; Rottschaefer and
Martinsen 1990; Ruse 1986; Vogeltanz and Plaud 1992; Wright 1994). The
promise is to employ science and reason to ground ethics on the firm
basis of nature (generally understood in terms of materialistic
metaphysics). Human survival and other goods contend for the role of
ultimate good, the end toward which evolution moves organisms.
Pragmatic approaches to ethics (R.A.Putnam 1991) emphasize practical
consequences. Strenger and Omer assert, for example, that “to be right a
SHAPING THE ETHICAL CHARACTER OF PSYCHOTHERAPY 271
construct must work,” albeit work in ways that meet certain tests of
coherence (Strenger and Omer 1992:126). The ethical and metaphysical
assumptions underlying pragmatic judgments (Tillich 1959; Richardson
and Fowers 1994) are generally downplayed in favor of experience (R.A.
Putnam 1991). A variety of ethical assumptions are held by pragmatists,
ranging from the de facto relativism of Rorty2 to the more substantively
ethical position of William James, whose pragmatism stressed the “moral
fruitfulness” of ethical alternatives (Browning 1991a:26).
Radical psychologists (D.R.Fox 1993) argue that mainstream
psychologists who adopt liberal values are coopted by an unjust status
quo. The values of the left ought instead be adopted. Psychology’s goals
should be substantive rather than procedural justice and a concern for the
general welfare (not just the best interest of individuals). And
psychologists should be willing to make ethical claims about the
goodness of particular societal ends.
Rational ethics—ethics based on reason—continues to have vigorous,
thoughtful advocates (e.g. Donagan 1977; Gert 1975, 1988). Indeed, most
theoretical ethics emphasizes reason to some extent. Although claims to
be able to derive certain ethical knowledge through reason are less
common than before, moderate rationalists (Drane 1991) still employ
reason and rational dialogue in ethical discourse that has more modest
aspirations than those purportedly held by champions of the
Enlightenment Project (MacIntyre 1984). Indeed, Taylor (1989) argues
that employing reason to address ethical issues is a major ethical source
contributing to the modern identity. Reason can, of course, be combined
with other ethical alternatives. Audi (1997), for instance, integrates
naturalistic and rationalistic elements.
Religious ethical perspectives, varying widely in style and content, link
ethics to diverse spiritual traditions and experiences. As noted elsewhere
in this book, religious and spiritual perspectives, including Buddhist,
Christian, Hindu, Jewish, Muslim, and others, remain live sources of
ethical convictions and action for many therapists, clients, and other
stakeholders. People of faith range from the anti-intellectual to the
scholarly (Browning 1987; Jones and Butman 1991; Taylor 1989).
Although some people are, as a matter of faith, dogmatically antireligious,3 Taylor notes that “in the actual life of modern culture,” ethical
alternatives such as “the clear vision of scientific reason, the Rousseauian
or Romantic inner impulse of nature, the Kantian good will,” and so forth,
“have not been treated as alternatives to or seen as incompatible with
religious faith” (Browning 1987:412).
Romanticism offers its own set of ethical visions, emphasizing
expressive fulfillment and the trustworthy inner impulse of a self that is
tied to nature (Taylor 1989; see Kirschner 1996). As Richardson and
Woolfolk note, Romantic moral philosophy “encourages us to eschew
false social masks and deceits and follow the ‘voice of nature’ revealed in
our unspoiled feelings and genuinely spontaneous impulses”
(Richardson and Woolfolk 1994:204).L. A.Sass (1988) points to a second
strand of Romanticism, upon which Heidegger drew, a strand
272 ETHICS AND VALUES IN PSYCHOTHERAPY
emphasizing community and tradition. The first strand of Romanticism,
which maintains that reason and high moral standards harm people
(Taylor 1989), tends to be emphasized by humanistic psychologists
(O’Hara 1997) and certain psychoanalysts (Kirschner 1996; Strenger
1997). Accordingly, their ethical assertions tend to be nonmoral and
covert.
Virtue ethicists, as discussed above, stress transformed persons and the
ethical qualities they ideally exhibit (Doherty 1995; Drane 1988, 1994;
Hauerwas 1995; MacIntyre 1984, 1988, 1990; W.F.May 1984; Meara et al.
1996; Punzo 1996; Thomas 1989). Sometimes sharply distinguished from
rational approaches that emphasize principles, virtue ethics can also be
seen as complementary to them. Virtue ethicists strive for a
psychologically sophisticated ethics that addresses motivation, emotion,
and social context.
Each of those fourteen ethical alternatives can undergird the
commitment of psychotherapists to professional ethics and help therapy
stakeholders to make ethical decisions about therapy process, therapy
outcome, and the ideal role of psychotherapy in a society.
A particular alternative (new or old) may yet prove superior,
consensually accepted by rational, intelligent people. I have not given up
hope. But my best guess is that all of those ethical approaches will
continue to receive support, with at least some thoughtful therapy
stakeholders finding each alternative best. Public philosophies regarding
therapy will thus ideally take that diversity into account. Societies should,
I believe, develop a public philosophy for psychotherapy that exemplifies
some form of genuine pluralism (Marsden 1991), a pluralism that permits
ethical diversity falling within broad bounds and excludes only clearly
harmful ethical alternatives.
Thinking
Learning to think well about ethical issues in therapy, to think carefully
and critically about practical therapeutic issues and therapy in general,
will benefit therapy stakeholders faced with ethical choices. Thinking
well involves drawing deeply upon one (and especially more than one)
of the ethical alternatives just discussed, applying ethical ideas to new
situations and ideas, and critically analyzing ethical ideas.
Therapy stakeholders striving to think well would benefit from sound
criteria for selecting ethical approaches, ordering principles, and
making particular ethical decisions. And general epistemological criteria
have been articulated. Martin and Thompson point to “conceptual
adequacy, internal consistency, external coherence, utility, conceptual
fruitfulness, emphatic resonance, and demonstrated empirical
possibility”
(Martin
and
Thompson
1997:647).
Rationality,
comprehensiveness, simplicity, authority, and positive consequences
have been proposed as well (Tjeltveit 1989). We lack a consensus about
which of these criteria is best, however. Indeed, Martin and Thompson do
SHAPING THE ETHICAL CHARACTER OF PSYCHOTHERAPY 273
not argue that the criteria they list will produce undeniable truth. They
argue, rather, for “pluralistic and pragmatic proposals that attempt to
combine, and perhaps to move beyond” those well-established criteria. In
addition, particular criteria are often tied to particular ethical
approaches. Advocates of rational ethics argue for rational criteria,
naturalistic ethicists argue for empirical criteria (of particular kinds), and
so forth. So the search for criteria, for ways to order competing values
and ethical theories, is only partially helpful.
Practice in addressing ethical issues and formal educational programs
(e.g. Vachon and Agresti 1992) can also help therapists to think well about
ethical issues in therapy. The use of case studies in conjunction with sets
of ethical principles can sharpen one’s ability to perceive ethical issues,
evaluate ethical alternatives, and decide on the best course of action.
Therapy stakeholders need more, however, than knowledge about
ethical alternatives, criteria for ethical decision-making, practice
addressing ethical issues, and training programs. We need practical
wisdom, the virtue I have stressed throughout the book (see Brody 1994;
Caplan 1989; Doherty 1995; Martin and Thompson 1997; Meara et al.
1996). A person with practical wisdom, or prudence, MacIntyre suggests,
“knows how to exercise judgment in particular cases” (MacIntyre 1984:
154). When faced with an ethical dilemma we often seek out those who
exhibit ethical wisdom. As Meehl (1981) notes, “We tend to adjust our
ethical system so as to increase its coherence with” the views of those
“who have engaged in extended rational ethical discussion based on
extensive real and vicarious experience” (Meehl 1981:7). Careful
reflection on ethical theory does not of course guarantee practical wisdom,
but those who are most wise will have thought about ethical issues
broadly, deeply, and well.
Dialogue
Better ethical decisions can result from talking with others, with Meehl’s
(1981) ethically wise persons, with friends, with colleagues, with those
who are practically minded and those who are philosophically minded,
with clients, with therapists. Ethical understanding, according to
Gadamer, “occurs through a process of dialogical exchange of views
during which good will (a serious, honest attempt to understand) is
extended to different perspectives” (Martin and Thompson 1997:641).
Dialogue of a sort can also occur, I think, with ethical ideas in works of
philosophy and art, in film, in poetry, in literature.
Ethical discourse in therapy is vitally important. Properly conducted
dialogue makes it more likely that therapists will address ethical issues in
accord with professional ethics. Those issues are explored, Doherty
argues:
274 ETHICS AND VALUES IN PSYCHOTHERAPY
in the heart of the therapeutic dialogue, in conversations in which
the therapist listens, reflects, acknowledges, questions, probes, and
challenges—and in which the client is free to do the same and to
develop a more integrated set of moral sensibilities.
(Doherty 1995:37)
Dialogues that are broad and dialogues that are focused can both play
important roles in making ethical decisions. By broad dialogues, I mean
conversations with persons holding substantially different ethical
perspectives. These dialogues among moral strangers (Engelhardt 1991)
can enrich, supplement, and confuse people. The person who is narrowly
religious may benefit by listening to, and taking seriously, the views of
those who are nonreligious or who are religious in different ways. And
the person who is militantly atheist may benefit by listening to, and
taking seriously, the views of those who are religious, because, as Bellah,
Madsen, Sullivan, Swidler, and Tipton suggest, the church “belongs in
the conversation of those seeking the right answers” (Bellah et al. 1991:
33). In the academic world, transdisciplinary approaches may be very
helpful. Rest (1988), for example, suggests drawing upon the expertise of
practitioners, of those in the normative disciplines (law, moral
philosophy, and theology), and of researchers in the social sciences.
Jahoda wanted input from politicians and “the man in the street” as well
(Jahoda 1958:80). And Doherty (1995) suggests the dialogue should
include economists and government officials, to which I would add thirdparty payers.
But focused dialogue within local ethical communities, communities
sharing particular ethical perspectives, can also play an important role in
helping therapy stakeholders to make ethical decisions. As Jaggar (1991)
notes, feminists can perhaps best pursue in-depth explorations of
feminist ethics with other feminists, so they need not continually revisit,
for example, the question of whether women’s experiences should be
taken seriously and oppression opposed. They can instead explore deeply
and thoroughly the implications of feminist ethics for therapy. Likewise,
suppose a conservative Jewish lady takes seriously (considers binding)
traditional Jewish interpretations of the Ten Commandments in thinking
about the ethical character of psychotherapy. Although she would
doubtless benefit from conversations with people who do not share those
views (as they would with her), if she is to explore her ethical convictions
deeply and well, she will need intense conversation in her local ethical
community, with those who share key convictions, so she can flesh out,
make deeper, and apply her ethical convictions.
SHAPING THE ETHICAL CHARACTER OF PSYCHOTHERAPY 275
Ethical articulacy
We are best equipped to make good ethical decisions when we clearly
articulate our ethical convictions. After noting that therapists “already do
provide moral consultation disguised as psychological consultation,”
Doherty (1995: 186) suggested that “we begin to do it more consciously
and explicitly.” We can easily articulate some therapy values (cf.
Fischhoff 1991), but not others. Identifying some values (and other ethical
convictions) may thus require us to engage in what Taylor (1989, 1992)
calls acts of retrieval. We will need, that is, to work at making overt what
is covert.
Clearly articulated ethical ideas can lead to better ethical decisions for
several reasons. As discussed in Chapter 11, practicing in accord with
codes of professional ethics requires therapists to be aware of their own
values and, sometimes, to communicate with clients about their ethical
convictions. Furthermore, as Socrates and others have argued, the
examined life is worth living (Taylor 1989). Being explicit about what we
think is good, right, and virtuous also helps us bring about goodness, to
act rightly, and to live virtuously. As Taylor put it, “seeing good makes
good” (ibid.: 454), as can be seen in Dostoyevsky, Nietzsche, and Genesis.
When explicit about the ethical ideals to which a particular identity is
implicitly tied, for example, we can live that identity more fully and
consistently (Taylor 1989).
As feminists and ethnic minorities have made clear, liberation can take
place when those whose experiences have been ignored and suppressed
give voice to their experiences and beliefs, including their ethical
convictions. Taylor notes that this sense of liberation by way of ethical
articulation has recurred throughout the history of philosophy.
Repudiating and denying ethical sources is self-stultifying. But when
philosophers “recover what has been suppressed and forgotten in the
conditions of experience” and articulate ethical sources, they experience
“exhilaration” and “liberation” (Taylor 1989: 460).
Finally, ethical articulacy connects us with ethical sources and
empowers us. In Taylor’s words, “articulation can bring us closer to the
good as a moral source, can give it power” (ibid.: 92). If a researcher
argues eloquently for elegance and fidelity to empirical evidence in
psychological theories, the researcher’s commitment to those two goods
may increase, and their effects on his or her life deepen. Clearly
communicating a good “can help realize the good by recognizing it” (ibid.:
454). This is true as well with goods, like autonomy, to which therapists are
committed. To explicitly convey to clients the goodness of autonomy may
empower them and enable autonomy to function for clients as what
Taylor calls a “moral source.”
Unfortunately, some people cannot find adequate language, cannot
find language that points convincingly to goodness. Accordingly, we may
need “new languages of personal resonance to make crucial human
goods alive for us again” (ibid.: 513).
276 ETHICS AND VALUES IN PSYCHOTHERAPY
Retrieving and drawing upon ethical sources
If therapy stakeholders aspire to create forms of psychotherapy with the
best possible ethical character and if “high standards need strong
sources” (Taylor 1989:516), stakeholders need to identify and draw upon
strong ethical sources. By sources, I mean what points us toward what is
good, right, and virtuous, what helps us to become good, right, and
virtuous, what ethically empowers us, “what moves us, what our lives
are built around” (ibid.: 92). Clients making profound changes, therapists
functioning at the highest ethical levels, and communities forging an
optimal role for therapy in a community will consciously build upon such
sources.
No one lacks such sources, though diverse sources exist and many
people are reluctant to name the genesis of, and consciously build upon,
their ethical ideas and actions. Those who want to make the best possible
ethical decisions about therapy will, I am convinced, articulate and draw
upon ethical sources, however.
Consistent with my stance throughout this book, I will not claim in this
section to identify the best source. In fact, with Taylor (1989), I think we
can and should draw upon more than one ethical source. But, with
Engelhardt, I am convinced that reason alone is too anemic a source for
healthy ethical functioning and that individuals will need to turn to
sources whose intellectual justification requires “special premises,”
premises that are “not open to general rational justification” (Engelhardt
1991:xiii). Adequate ethical sources provide therapy stakeholders with
content. But, “content is particular, the particular is parochial, and the
parochial has moral substance” (ibid.: 140). Those drawing upon contentfull ethical sources will thus draw upon particular ethical sources
associated with particular ethical communities, local ethical
communities, such as the feminist, the scientific, or the Reformed Jewish.
Because these diverse ethical sources exist and individual differences
should be respected, public philosophies regarding psychotherapy
should be pragmatically and genuinely pluralistic.
People report drawing upon a variety of ethical sources. Bellah,
Madsen, Sullivan, Swidler, and Tipton (1985) point to “the notion that
one discovers one’s deepest beliefs in, and through, traditions and
community” (Bellah et al. 1985:65). Browning notes that some think of
psychology “as a practical discipline based on a critical ethic and a
critical theory of society” (Browning 1987:xi). In my terms, such an
“ethic” and “theory” serve as ethical sources for those psychologies.
Engelhardt suggests that people seeking particular content-full moralities
turn to “tradition, culture, or God’s good grace” (Engelhardt 1991:195).
Communities can be ethical sources in three ways: they can themselves
serve as ethical sources, they can point to ethical sources, and they can
make it easier for individuals to draw upon ethical sources. A wide range
of traditions and communities exist, however, ranging from the traditions
of postmodernism and classic liberal individualism to those of ancient
SHAPING THE ETHICAL CHARACTER OF PSYCHOTHERAPY 277
religions still practiced. Guignon suggested that we can “find guidance”
in stories about “the lives of models or exemplars drawn from history”
(Guignon 1993:234). That is, narratives can function as ethical sources.
L.A.Sass (1988) pointed to the communal, the social, and the traditional,
noting that those sources need not be in opposition to individuality,
freedom, and critical self-reflection. Indeed, some traditions and
communities strongly affirm, and even require, those ideals. Taylor
pointed to a variety of ethical sources, most of which people in the West
implicitly draw upon without recognizing they do so. Scientifically
oriented psychologists may not, for instance, recognize their reliance on
the great “power of naturalist sources” (Taylor 1989:518). He also
identified as sources “the clear vision of scientific reason,” the “inner
impulse of nature,” the “Kantian good will,” and grace (ibid.: 412). Ethical
sources “may be divine, or in the world, or in the powers of the self’
(ibid.: 490). Finally, ethical sources may be outside the self, but accessed
through languages that resonate within people, for instance, the sources
that Taylor thought held the greatest potential, the sources to which
Dostoyevsky pointed.
Psychotherapy stakeholders will, no doubt, continue to draw upon a
wide range of ethical sources in making decisions about the ethical
character of therapy. Thoughtfully and critically retrieving and drawing
upon those ethical sources is vital—for the sake of psychotherapists, for
the sake of society, and for the sake of psychotherapy clients.
Notes
1
Introduction
1 I use the phrase “mental health” as a summary term for all therapy goals.
Accordingly, by using it I do not intend to endorse a “medical model”
understanding of psychotherapy. I use it, rather, in its broad sense of a
“chapter title” (Smith 1961:304) of a “chapter” that contains all concepts
pertaining to therapy goals. In this sense, “mental health” refers to the
treatment goals of both the biologically oriented psychiatrist and the nontraditional, humanistically oriented therapist.
2 See Stiles (1983), and Strupp and Hadley (1977). The latter argue that, in
addition to the therapists’ perspectives on therapy goals, the voices of
clients and the general public need to be heard as well.
2
Ethics: challenging, inescapable questions
1 Providing less-than-fully competent therapy is not an ethical violation per
se. Determining whether a code of professional ethics has been violated
would require more information about the case.
2 Many professionals draw upon the full range of ethical considerations in
making professional ethical judgments. In drawing this distinction among
six types of approach to ethics, I acknowledge that the six may overlap;
indeed, they should. The contrast I am drawing is between the ethics codes
professionals employ (professional ethics narrowly conceived) and other
approaches to ethics.
3 Philosophers (e.g. Flanagan 1991; MacIntyre 1984, 1988, 1990; Nussbaum
1994), biomedical ethicists (e.g. J.F.Drane 1988, 1994; W.E.May 1984), and
theologians (e.g. Hauerwas 1995; Meilaender 1984) have recently shown
increased interest in virtue ethics.
4 Cf. critiques of individualism in Hippocratic medical ethics (Veatch 1989b),
in society in general (Bellah et al. 1985; Fox-Genovese 1991; MacIntyre
1984), and in psychology (Prilleltensky 1994; Sampson 1993; Wallach and
Wallach 1983).
NOTES 279
5 Hare-Mustin defines discourse as “a system of statements, practices, and
institutional structures that share common values” (1994:19).
6 For example, see discussions by bioethicists (Callahan 1995), philosophers
(Adams 1987; Pojman 1995b), developmental psychologists (L.Kohlberg
1971), evolutionary ethicists (Campbell 1975; Wright 1994), feminists
(Morawski 1994), philosophical psychologists (Bickhard 1989), and
empirical researchers (Petrinovich et al. 1993).
3
Psychotherapists as ethicists: engaging in difficult, essential tasks
1 Veatch notes, however, that some ethical traditions “do recognize
authorities in the values and normative judgments made within their
traditions” (1989a:12). In such traditions, teachers would be expected to
teach the ethical perspectives of that authoritative tradition. Therapists not
adhering to such a tradition may be tempted to engage in subtractive ethical
influence with clients from such traditions, to be advocates of their own
view and critics of those traditions.
2 Some think mental health and other therapy goals are concepts that are
inextricably ethical, and so would challenge sharp distinctions between
mental health and ethics. This dispute will be addressed in Chapter 9.
5
Unpacking diverse understandings of “values”
1 Taylor (1989) distinguished between two families of views: the Kantian
with its emphasis on disengaged autonomy as central to morality, and the
Expressivist perspective which focuses on nature as moral source.
2 Rogers (e.g. 1964) appeared to view “ought” in a wholly negative light.
Maslow (1963), by way of contrast, reported that self-actualized persons
have a healthy sense of “ought.”
6
The intellectual contexts of psychotherapy: ethics and science
1 When I use “science” in this section, I use it as some of its advocates portray
it: as an objective, value-free set of procedures that, in conjunction with
data, can produce dependable knowledge. As I shall discuss later,
however, sharply distinguishing ethics from science is difficult. And some
deny we should.
7
The social contexts of psychotherapy: clinical practice and business
1 An important ethical issue which I will not discuss further in this chapter is
that of a right to health care. Engelhardt asserts that “a basic human secular
280 ETHICS AND VALUES IN PSYCHOTHERAPY
moral right to health care does not exist—not even to a ‘decent minimum of
health care.’ Such rights must be created” (Engelhardt 1996:375). And
Brennan (1993) notes that a legal basis for a universal right to health care
does not exist in the US constitution. The failure to adopt universal health
care coverage in the US indicates that Americans do not believe that such a
right exists, do not want to create one, or both. Or at least that they do not
want to pay for it. Those who claim that such a right exists, or should be
created, need to make more convincing ethical arguments to that effect, a
difficult task given the (perhaps incommensurable) diversity of
contemporary ethical views.
But even if we assume that a right to health care exists (as many in the
world do), a second problem must be faced: the nature and extent of the
health care guaranteed by that right. One way to get at that problem is to
look at the goal of health care: health. A right to health care assumes the
goodness of health. But what is the nature of that health, and what level of
health do people have a right to receive? The right of the severely mentally
ill to receive basic treatment to manage their disorders is quite different
from (and easier to defend than) the right of the “worried well” or the
“adventuresome seeker of personal growth” to reach therapy goals like
character reconstruction or self-actualization. It is conceivable that a right to
the former exists, but not a right to the latter, especially if establishing such
a right causes damage to a society. The question of a right to health care
may thus be tied to the ethical character of therapy goals, a topic addressed
in Chapter 9
8
Ethical dimensions of the techniques, strategies, and processes of
therapy: which means to therapeutic ends?
1 Judgments of effectiveness can, of course, be made only with reference to
the goals of therapy. Those ethical evaluations of therapy process thus
overlap with ethical evaluations of therapy outcome.
2 The first four come from Beauchamp and Childress (1994), and the fifth
from K.S.Kitchener (1984).
3 See Drane’s (1994) discussion of physician virtues, and Kitchener (1996b)
and Meara et al. (1996) on therapist virtues.
4 They used different methodologies to summarize research findings than
did Orlinsky et al.
9
Ethical dimensions of the goals and outcome of therapy: therapy as
means to which (ethics-laden) ends?
1 Family therapist Boszormenyi-Nagy (1987; Boszormenyi-Nagy and Krasner
1986; Boszormenyi-Nagy and Sparks 1984), for instance, argues that family
members should be just (fair) with one another. Establishing the therapy
goal that clients further social justice, addressing justice in macro-ethical
NOTES 281
2
3
4
5
6
7
situations (Clark 1993), is less common, however, although Cushman (1995)
and Doherty (1995) clearly support clients who pursue that broader aim.
As noted in Chapter 1, I use this phrase as a summary term for all therapy
goals, including those held by persons who would not use the term.
Those who have empirically or conceptually distinguished mental health
values (or similar or related concepts) from moral or other values include
Bergin (1985); Blatt (1964); Buhler (1962); Fine and Nichols (1980); FrommReichmann (1953); Ginsburg (1950); Hartmann (1939, 1960); Haugen et al.
(1991); Jensen and Bergin (1988); Katkin and Weisskopf-Joelson (1971);
Kelly and Strupp (1992); Kubacki (1994); Margolis (1966); Michels (1976);
Naranjo (1970); Neulinger et al. (1970); K.V.Schultz (1958); Strupp (1980);
Strupp and Hadley (1977); Suan and Tyler (1990); Tjeltveit (1986); Tyler et
al. (1983); Tyler et al. (1989); and Tyler and Suan (1990).
The literature addressing the relationship of mental health/
psychotherapy and values/morality/ethics is extensive. Books addressing
it include Andrews (1989); Brandt and Rozin (1997); Browning (1987);
Browning et al. (1990); Buhler (1962); Caplan et al. (1981); Coan (1974, 1977);
Cushman (1995); Doherty (1995); Dokecki (1996); Engelhardt and Spicker
(1978); Fairbairn and Fairbairn (1987); Frank and Frank (1991); Glad (1959);
Hartmann (1960); Holmes and Lindley (1989); Jahoda (1958); Lakin (1988,
1991); Lear (1990); London (1986); Lowe (1976); Margolis (1966); Miller
(forthcoming); Mowrer (1967); Norton (1976); Nunnally (1961); Offer and
Sabshin (1966); Post (1972); Prilleltensky (1994); Rieff (1966, 1979); D.Schultz
(1977); M.B. Smith (1969); Wallach and Wallach (1983); Weiner (1993); and
Woolfolk (1998).
Ethical ideals may, of course, be evaluated in other ways. My tests are all
teleological, for example. If we were drawing upon virtue ethics or
deontological normative theories, we would ask different questions when
evaluating therapy ideals.
Wallace notes “the tortuous complexity and ambiguity of [Freud’s ethical]
thinking and attitudes” (Wallace 1986:101). He outlines no less than twelve
“desiderata implicit and explicit in Freud’s ethics” (ibid.: 118). See also
Wallach and Wallach (1983) and Browning (1987) on the tensions within
Freud’s thought.
The Greek word “eudaimonia,” usually translated as “happiness,”
Nussbaum (1994) argues, is better translated as “human flourishing.”
Cf. the special section in the Journal of Social and Clinical Psychology, edited
by Harvey (1985).
10
Rethinking psychotherapy’s location in a society: public philosophy
and social and therapeutic contracts
1 An extended discussion of the meanings of “public philosophy” (see Bellah
1986; Browning and Evison 1991; Dewey 1930; Kirschner 1993; Neuhaus
1984; Niebuhr 1944; Sandel 1996; and W.M.Sullivan 1982) is beyond the
scope of this book. I will focus here on the ethical dimension of a public
282 ETHICS AND VALUES IN PSYCHOTHERAPY
2
3
4
5
philosophy rather than on the political dimension emphasized in much of
that literature. I use the term more broadly than Lippmann (1956) and do
not intend it to have a particular ideological slant, save that of an
opposition to relativism, authoritarianism, and ethical inarticulacy.
Drane (1991), Guignon (1993), G.S.Hall (1923, cited in Morawski 1982),
London (1964, 1986), Lowe (1976), Michels (1991), Strupp (1992), Wachtel
(1989), and Wallace (1991).
McNeil notes, for example, that priests in Judaism were concerned with
worship and ceremonies, not with “the principles of the good life and
details of personal conduct” (McNeil 1951:2), which were addressed by
religious leaders occupying the separate role of “wise man.”
“Consensus” carries more philosophical weight (and disguises more varied
philosophical positions) than any one term perhaps ought to carry (and
disguise). Cf. Moreno (1995). This brief overview will of necessity omit
many nuances from the argument. It should be noted that contestants in
this philosophical debate often do not agree with their opponents’
characterizations of their views. My use of examples in this section should
be seen, therefore, as illustrative rather than as definitive expositions of
particular authors’ views.
Bok identified three minimalist values: “some form of positive duties
regarding mutual support, loyalty, and reciprocity”; “negative duties to
refrain from harmful action”; and “norms for at least rudimentary fairness
and procedural justice in cases of conflict regarding both positive and
negative injunctions” (Bok 1995:13, 15, 16).
11
Profession and professional ethics
1 The extensive debates about the meaning of professionalism are beyond the
scope of this book. See Abbott (1988); Callahan (1988); Camenisch (1983);
Fulford (1989); Goldman (1980); Hatch (1988b); Jennings et al. (1987);
Kultgen (1988); MacNiven (1990); L.May (1996); and W.M.Sullivan (1995).
2 Roazen describes such therapists in these terms, “moral positions are taken
via clinical categories without any awareness that the same categories might
justify very different moral alternatives” (Roazen 1972:202).
3 Michels stated baldly “I believe it is immoral to disguise rhetoric as
therapy” (Michels 1976:383).
12
Shaping the ethical character of psychotherapy: inevitable choices,
better choices
1 These correlate, roughly, to Bellah, Madsen, Sullivan, Swidler, and Tipton’s
(1985) utilitarian individualism, expressive individualism, and Biblical
individualism. Taylor, however, sketches the history of these “spiritual
families” (1989: 502) or ethical sources within the history of Western (and
especially European) thought instead of focusing on the US, points to the
NOTES 283
deep tensions between the sources, describes each source in a way that its
ethical strengths are evident, and argues that the modern self contains
elements of all three. He argues that whenever only one is acknowledged,
the less dominant families are still present, hidden from view.
2 “It is crucial to Rorty’s postmodernist view of our situation,” Guignon
notes, “that we see morality as nothing other than the practices a group
happens to commend at a given time” (Guignon 1991:95).
3 They illustrate Engelhardt’s third sense of “secular humanism.” For them,
“Secular Humanism is a concrete moral vision. It is instantiated in
particular moral communities that regard themselves in competition with
religious sects” (Engelhardt 1991:125). As noted in Chapter 10, those who
are “secular humanist” in his other two senses of the phrase attempt to
formulate ethical positions that “span and tolerate” (ibid.: 139) diverse
religious and non-religious ethical claims.
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Index
Abe-Kim, J.S and Takeuchi, D.T. 145
absolutism 41, 54–56, 103, 185,
see also relativism
Adams, R.M. 64, 73
adaptation 192, 210, 212
affirmation 205, 216, 239–50
Agich, G.J. 41
Al-Ghazzali, Muhammad 128
Albee, G.W. and Ryan-Finn, K.D. 227
Albert, E.M. 95
Alderman, H. 87
Aldrich, C.K. 225
Allport, G.W. 89–6, 210
Allport-Vernon-Lindzey Study of
Values 89–6
altruism 66–2
ambiguity, tolerance of 170
American Association for Marriage
and Family Therapy 17
American Medical Association 18
American Psychiatric Association 17,
128, 177, 245
American Psychological Association
(APA) 25, 67, 115;
codes of ethics 17, 18, 37, 81, 112,
130, 156–5, 247, 254–5;
Division of Family Psychology 227
American Psychological Society (APS)
25, 115, 133
Amundsen, D.W. 17
Annas, J. 30, 198
Aponte, H.J. 164, 171, 173
applied ethics see clinical ethics
Aquinas, Thomas 63, 73
aretaic ethics 57–2, 104
Aristotle 63, 64, 72, 128, 154, 194, 206,
213, 215, 217
Association of State and Provincial
Psychology Boards 225
Audi, R. 270
Augustine, St 213
Austad, C.S. 139, 145
Austad, C.S. and Berman, W.H. 135,
141, 179, 211, 217
authoritarianism 54, 210, 232–3
autonomy 268;
of client 158, 161–70, 187–5, 191–9,
200, 207, 250;
professional 224, 227
“axiology of inquiry” 115–3, 118, 121
Ayer, A.J. 53
Bacon, Francis 114–2
Ballard, B.W. 236
Bandura, A. 48
Baritz, L. 136
Barlow, D.H. 112–20
Batson, C.D. 66
Bauman, Z. 56
Beauchamp, T.L. and Childress, J.F. 68,
131
behaviour, ethical 265–6
behaviourism, 161, 218
Bellah, R.N. 230
Bellah, R.N., Madsen, R., Sullivan,
W.M., Swidler, A. and Tipton, S.M.
102, 104, 204, 207, 209, 227, 237, 259,
273, 275
Benedict, Ruth 61
321
322 ETHICS AND VALUES IN PSYCHOTHERAPY
beneficence 178–7, 184, 185, 245, 251,
258
Benne, R. 230
Berger, M. 208
Bergin, A.E. 2, 2, 48, 250
Berkowitz, P. 87–4, 101
Bersoff, D.N. 68, 254–6
Beutler, L.E. 104
Beutler, L.E. and Clarkin, J.F. 201
Beutler, L.E. and Harwood, T.M. 110
Bickard, M. 162, 163
bioethics 18, 20, 42, 124, 126, 129–8, 233
Birch, B.C. and Rasmussen, L.L. 226,
265–6
Blanck, R.R. and DeLeon, P.H. 133
Bok, S. 238
Boss, Medard 64
Braithwaite, V.A. and Scott, W.A. 90,
92
Brentano, Franz 84–1
Brink, D.O. 56–1
Brody, H. 65
Browning, D.S. 63, 156, 172, 202, 211,
214, 217, 224, 228–9, 267, 275
Buber, M. 162
Buhler, C. 217
Burns, D.D. 103
business context 132–52
Callahan, 18, 20, 22, 24, 26, 27, 28, 232
Campbell, D.T. 62
Caplan, A.L. 33, 36, 37, 39, 253
Cartwright, Samuel 128
case-oriented (bottom-up) decision
making 23–6
casuistry 23, 268
Catholic fathers 124
Cattell, R.B. 67, 112
Chambless, D.L. 231
change 124, 165;
processes 155–4, 202–12;
unintended 166–5, 202–10
character 24
Christopher, J.C. 170, 195
citizenship, 227
Clark, C.R. 223
client, background 92–9;
freedom 169, 173–2, 179;
informed consent 159–9, 240, 250–1;
right to disagree 176;
self-interest 208, 209, 216–5;
values 5, 37, 47–2, 254,
see also autonomy;
influence
client/therapist, agreement 158–7, 167;
“moral strangers” 240–1, 252;
shared ethical ideals 239–50, 250
clinical context 92–9, 124
clinical ethics 19, 22–6, 26, 27, 37, 44
clinical judgement 172, 174
clinical psychotherapy, a-social 127;
reality 131–9
Clouser, K.D. 24
codes of ethics 17–19, 20, 81, 156–5,
246–67;
constraints on 258–9
coercive therapist processes 167–6,
see also influence
cognitive errors of psychotherapists 39
communitarians 238, 268–9
communities, as ethical sources 275–6
confidentiality 17, 24, 140, 159, 258
conflicts see ethical dilemmas
consensus/custom, ethics 29, 60, 193
Consoli, A.J. 192, 206
Consoli, A.J. and Beutler, L.E. 7, 92,
97–4
context 156;
business 132–52;
clinical 92–9, 124;
cultural 93, 201, 267;
social 124–52;
therapist’s background 92
contracts, therapeutic 225, 241–3, 248
“corporatization” of health care 137
corrective emotional experiences 155
cosmopolitans 238
counterconditioning 155
Cournand, A. 114
creativity and morality 87–4
cultural context 93, 201, 267
cultural ethics 19, 27–28, 37, 44, 54, 222
Cummings, N.A. 129–7
Cushman, P. 27, 43, 44, 101, 127, 156,
177, 209, 248, 252
INDEX 323
Cyrenaics 206
Darwin, Charles/Darwinism 83–84, 85,
86, 89
Davis, K. 141
decision making 23–6, 173
deconstructionism 87
definism 61–9
deontological ethical theories 57, 58,
64–65, 67–4, 75, 104, 120, 152
Derrida, Jacques 86
Descartes, René 200, 213
Detmer, D. 86
Dewey, J. 183
dialogue 163–2, 272–4;
between “moral strangers” 273;
between stakeholders 231–2, 235,
250–1;
within ethical communities 273–4
Dickson, P. 82
disinterest/objectivity 37
divine revelation and ethical
knowledge 73
dogmatism 54
Doherty, W.J., clinical judgement 172;
dialogue 273;
ethical empowerment 196, 202;
ethical influence 42–5, 44, 162, 164,
168, 174–3, 176, 252, 260;
individual/societal well-being 67,
209, 210, 211, 217, 247, 248, 263;
obligations 104, 204, 237;
personal fulfillment 237;
responses to clients 174, 176–6;
scientific ideas in therapy 111;
social context 135–3, 144;
and virtues 24, 65, 154, 213, 250
Dostoyevsky, Fyodor 274, 276
Drane, J.F. 24, 260
Dreikurs, R. 175
DSM-IV (Diagnostic and Statistical
Manual of Mental Disorders) 128
Dwairy, M. and Van Sickle, T.D. 201
Dyer, A.R. 24
Dyer, A.R. and Bloch, S. 159
economic reductionism 142–51, 229
Edel, A. 23, 90, 96
education, as change process 155
egoism 66–2,
see also selfishness
Elliott, R. and Anderson, C. 156
Ellis, A. 41, 51, 103, 196
Ellis, A. and Bernard, M.E. 208
emotivism 53, 163, 185
Engelhardt, H.T. Jr 166, 233, 234, 237,
238, 239–50, 275
Engelhardt, H.T. Jr and Wildes, K.W.
64–9, 237
Engler, J. 213
Enlightenment 70, 83, 85
Enlightenment Project 270
ERDERVE (Extended Rational
Discussion based on Extensive Real
and Vicarious experience) 64
Erikson, E.H. 172
ethical acuity 262
ethical agnosticism 112–20
ethical articulacy, 274–5
ethical assertions, justification 57, 60,
64;
meaningless 53, 81–7;
rationality of 47, 47, 53–8;
and religion 47
ethical convictions 161, 168, 173–2,
177–6;
implicit in scientific inquiries 118,
119;
maximalist/minimalist 40;
“moral realism” 56–1;
of therapist 173
ethical dilemmas 47–3, 68-4
ethical discourse see dialogue
ethical diversity 233–51, 244, 252
ethical empowerment 196, 202, 213,
275
ethical ideals 186–6, 193, 202–14, 226–9;
balance 226–8, 262–4;
business justifications 228;
consensus 204, 214, 236–9;
disagreement 228;
rejection of 204, 216,
see also goodness
ethical judgements 64, 172–1;
about outcome 185;
324 ETHICS AND VALUES IN PSYCHOTHERAPY
client client’s character 58;
and context 55
ethical knowledge 69–9
“ethical objectivism” 56
ethical principles 56, 64, 68, 69, 152–60,
187–5, 204–14
ethical theory see positivist ethical
theory;
theoretical ethics
ethicist, definition 32, 35–8, 37;
influence on others 40–5, 252;
roles 39–5, 44;
as teacher 41
ethicist/moralizer distinction 32–6
ethics 15–31;
consensus/custom 29, 60, 193;
definition 29–4;
dimensions of 15–28;
ethical critique 101–12;
ethics/values relationship 31–4;
and psychology 107–16;
science/ethics relationship 28–1
evaluation, of therapeutic goals
182–90, 187, 193
evolutionary ethics 62, 269–80
existentialism 64, 72, 87, 91
expansionists 112
expertise, ethical 33–9, 37, 44–7, 157
extra-rational personal qualities 72
fact/value dualism 84
Fancher, R.T. 101
feminism/feminists 4–5, 233, 234;
bioethics 62, 101;
ethical assumptions 228;
ethics 23, 54, 73, 269;
and naturalistic ethics 62;
therapists 51, 159–8, 213
Feminist Therapy Institute 4–5, 159–8,
173, 250
Fishbein, M. and Ajzen, I. 79
Flanagan, O. 63
Follette, W.C., Bach, P.A. and Follette,
V.M. 193
Foucault, M. 55, 86, 246
Fowers, B.J, Tredinnick, M. and
Applegate, B. 227
Fox, R.E. 133, 135, 144–2
Franck, I. 214
Frank, J.D. 207
Frank, J.D. and Frank, J.B 150, 159, 167
Frank, R.G. and VandenBos, G.R. 223–4
Frankena, W.K. 30, 58, 59, 65, 67, 79, 83,
109, 188
Frankfurt School 269
Franklin, G. 170–9
freedom 82, 102, 105, 155, 169, 173–2,
179;
from mental illness 128, 194, 207,
225, 235;
from moral obligation 27
Freud, Sigmund 103, 153, 190, 207, 211,
213, 214, 217;
and adaptation 196, 210;
and client autonomy 179;
and influencing clients 112, 175;
and moral obligation 157, 204–13;
and neutrality, 107–15, 162, 226;
role of therapy 191–9, 225;
and social contexts 128;
and therapist self-disclosure 149;
and virtues 212
Freudians 61, 66, 200
Fromm, Erich 103
Fulford, K.W.M. 152
Gadamer, Hans-Georg 269, 272
Garfield, S.L. 6
Geller, L. 213
general welfare see society
Gerber, L.A. 248
Gergen K.J. 55
Gewirth, A. 194–2
Glad, D.D. 192
Glasser, W. 173, 205
goals see therapeutic goals
goals/outcome distinction 182
“golden rule” 103
“good life” 82–8, 88, 101, 102, 103, 207,
232
goodness 47, 53–69, 105, 109, 188–6,
206–20;
religious perspective 75;
and science 119,
INDEX 325
see also values
“Great Synthesis” (seven virtues) 73
Guignon, C.B. 64, 74, 183, 207, 212–1,
226, 267, 276
Haas, L.J. and Malouf, J.L. 17
Habermas, Jürgen 164, 266, 269
Halakha 76
Hale, N.G. Jr 101
Hall, C.S. and Lindzey, G. 208
Hall, G.S. 106, 117
Hall, M.A. 224, 226, 247, 268
Hammond, K.R., Harvey, L.O. and
Hastie R. 232
Handelsman, M.M. Kemper, M.B.,
Kesson-Craig, P., McLain, J. and
Johnsrud, C. 160
Handy, R. 94
Hare, R.M. 266
Hare-Mustin, R.T. 27–28
Hare-Mustin, R.T., Marecek, J., Kaplan,
A.G. and Liss-Levinson, N. 156
Hartmann, H. 31, 108, 171, 190, 191,
198, 201, 219
Haugen, M.L., Tyler, J.D. and Clark,
J.A. 192
health care spending 141–9
health insurance 137, 138, 223
Health Options Oversight Panel
(HOOP) 52
Health Options Systems Services
(HOSS) 52, 53, 57, 68, 71, 132
Heidegger, Martin 64, 212–1, 215, 263,
267, 269, 271
Henderson, 89
Herder, Johann Gottfried von 213
hermeneutics 74, 91, 269
Herron, W.G, Javier, R.A., Primavera,
L.H. and Schultz, C.L. 202
Hill, C.E. 156
Himmelfarb, G. 230
Hippocratic Oath 17, 126, 127, 130
Hoffman, J.C. 176
Hofstadter, R. and Metzger, W.P. 114
Hoge, D.R. 75
Holmes, A.F. 64
Hopkins, Mark 106–14
Horney, Karen 103
Howard, G.S. 114
Hull, Clark 112, 116
human nature 71–7, 109–17, 214–3
humanism, secular 238
humanistic psychologists,
individualism 45, 90–7, 205, 207, 208,
218;
and naturalistic ethics 62–7, 88, 189;
virtues 212
Hume, David 72
“hypergoods” 218
idealism, philosophical 84
Imber, S.D., Glanz, L.M., Elkin, I.,
Sotsky, S.M., Boyer, J.L. and Leber,
W.R. 110
individualism 203, 204, 208–17, 215,
227, 237, 265;
liberal 268;
personal growth 183, 208;
training 83
influence on client 47, 48, 96–3, 164–86,
248–65, 264;
additive/subtractive 41, 42–5;
denial 159;
imposing values 10–11, 42–5, 150–8,
235, 240–1
instinct, and ethical knowledge 72
interactional neutrality 170
intuitionism 64, 174–3
Jacobs, L. 76
Jafari, M.F. 211
Jaggar, A.M. 228, 233, 236, 273
Jahoda, M. 4, 128–6, 191, 192, 208, 210,
214, 273
James, William 73, 89, 106, 121, 122–30,
270
Jennings, B., Callahan, D. and Wolf,
S.M. 232
Jensen, J.P. and Bergin, A.E. 4, 97–4,
159, 192, 206, 238
Jewish ethicists 76
Johnson, J.P. 81, 83, 84
Johnson, M. 109
Jones, S.L. and Butman R.E. 212
326 ETHICS AND VALUES IN PSYCHOTHERAPY
Jonsen, A.R. 23
Journal of Social and Clinical Psychology
167
judgement see clinical judgement;
ethical judgements
judgmentalism 168, 170
Kant, Emanuel 83, 161, 206
Karasu, T.B. 108, 185
Karon, B.P. 133
Kaufmann, W. 87
Kellner, M.M. 76
Kelly, E.L. 129
Kelly, E.W. 76, 97–4, 192, 206
Kendler, H.H. 71, 106, 115, 116–4, 231
Kiesler, C.A. and Morton, T.L. 223
Kirschner, S.R. 61, 101
Kitchener, K.S. 29, 65, 67, 68, 254–5,
256
Kitchener, R.F. 48, 79–6
Kitwood, T. 153, 162
Klein, Joe 102
Kluckhohn, C. 83–9
Knapp, M. 145
Koch, S. 8, 53
Kohlenberg, R.J. 6
Koocher, G.R. 248
Kovacs, A.L. 168, 175, 230
Kovel, J. 128
Krause, M.S. and Howard, K.L. 231
Kristiansen, C.M and Zanna, M.P. 82
Kubacki, S.R. 164
Kultgen, J.H. 26, 247
Kurtines, W.M., Alvarez, M. and
Azmitia, M. 119, 171, 264
Lamarckian biology 117–5
Lambert, M.J. 154
Laudan, L. 115–3, 118, 184, 260
Leahey, T.H. 8, 117, 183
Lear, J. 214
Leary, D.E. 116
Lewin, Kurt, 117
London, P. 225, 248, 261–2
Long, E.L. Jr 73
long-term effect of therapy 204–12, 205
Lotze, R.H. 84, 89
Lovinger, R.J. 160
Lowe, C.M. 160, 179
Luther, Martin 101
McClure, G. and Tyler, F. 117
McDougall, William 117
McFall, R.M. 105, 111
McGuire, T.G. 134, 144
MacIntyre, A., contexts 101, 101, 142;
ethical knowledge 61, 70, 73, 74;
ethical theory 163, 215;
goodness 229, 238;
on Nietzsche 87
Macklin, R. 35, 161
Mahoney, M.J. 204, 261
Maimonides, Moses 73
Managed Care Organizations (MCOs)
137–5
managed health care 133, 137–5, 210
Margolin, G. 48, 160, 178
Margolis, J. 128, 191
Martin, J. 121
Martin, J. and Thompson, J. 272
Marty, M.E. 63, 233
Maslow, A.H. 64, 79, 82, 88, 90, 209,
212
May, L. 248
May, R. 170
May, W.F. 187, 245, 254, 256
Meara, N.M., Schmidt, L.D., and Day,
J.D. 24, 65, 68, 91, 152, 154, 187, 227–8,
229, 250
medical ethics 17–18,
see also bioethics
Meehl, P.E. 40, 64, 119–7, 122, 173, 272
Meehl, P.E. and McClosky, H. 130
Mencken, H.L. 10
Menninger, K.A. 130
mental health 128, 190–199, 225, 235;
definitions 4, 128–6, 186, 190–8, 192,
196–4, 212, 265;
dysfunction 195, 203;
as “hypergood” 218–7;
medical-ethical concept 126, 127–6;
minimalist/maximalist concepts
194, 196, 197, 202;
INDEX 327
moral/nonmoral values 128–5,
197–6;
positive 194, 195–3, 208;
as therapeutic goal 2, 5;
values 191–193
mental illness, economic consequences
135;
freedom from 128, 194, 207, 225,
235
metaphysical assertions 63
Michael, J. 218, 228
Michels, R. 26, 37, 79, 208, 218, 219, 226,
235, 238
Minsel, B., Becker, P. and Korchin, S.
192
Montaigne, Michel de 200, 213
moral obligation 27, 57–2, 60, 204–13
moral philosophy, definition 19,
see also theoretical ethics
“moral realism” 56–1
“moral sense” 72
moralist, definition 32
morality, definition 29–2, 87;
history of 83–85;
moral-nonmoral distinction 30–3,
57, 59;
morality/ethics distinction 29–2;
social contract 60–5;
tradition 61, 69
Morawski, J.G. 117
Munsterberg, Hugo 89, 117
Nagy, T.F. 20, 112
narrative see hermeneutics
National Association of Social Workers
17
“natural law” 72
naturalistic ethics 62–7, 82, 87–5,
269–80, 272
“nature of things” 61–6, 63
Neo-Cognitive Therapy 109
neo-Freudians 103, 218
Neo-Nietzscheans 86, 96, 246, 256
Nerlich, G. 82
neutrality 169–81, 170, 171, 172, 175,
226, 235, 243
new morality see Nietzsche
New York Psychiatric Society 130
Newton, Sir Isaac 114–2
Nicholas, M. 175, 178, 196, 206, 210,
213
Nietzsche, F.W., benevolence, 233,
245–6;
“Immoralist” 101–9;
individualism 209, 215;
reason 70;
self-scrutiny 153;
values 84, 85–5, 90, 91
Noddings, N. 73
non-naturalism (intuitionism) 64, 174–3
nonmaleficence 251
normality 190, 201
normative ethics 64, 81, 87–4, 121
Nussbaum, M. 194
Odell, M. and Stewart, S.P. 197, 217,
250
O’Donohue, W. and Mangold, R. 255
“organismic/common nature” 83, 90
Orlinsky, D.E. 101, 126, 241, 242
Orlinsky, D.E., Grawe, K. and Parks,
B.K. 150, 154, 156
Orlinsky, D.E. and Howard, K.I. 182
outcomes see therapeutic outcomes
Ozar, D.T. 26–9
Parloff, M.B. 112, 196, 200, 241
Parloff, M.B., Goldstein, N. and Iflund,
B. 253
Pascal, B. 72
paternalism, as therapy process 168,
178
Patterson, C.H. 214, 219
Pedersen, P.B. and Marsella, A.J. 253–4
Pellegrino, E.D. 245
Peperzak, A. 81
Perrez, M. 121, 150
Perry, R.B. 79, 122–30
Pilgrim, D. and Treacher, A. 101
Plato 63, 128, 194, 206, 213
Pojman, L.P. 19, 30, 54, 56, 67
Popper, K.R. 114–2, 116
positive evaluation, as therapy process
168
328 ETHICS AND VALUES IN PSYCHOTHERAPY
positivism 108, 112, 163, 259–70
positivist ethical theory 8–9, 28, 53–8,
57, 185
postmodernists 82, 86, 102;
affirmative/skeptical 56, 70, 245,
255, 256, 259–70
pragmatism 185–3, 186, 228, 270
Prilleltensky, I. 56, 81, 92, 217, 228, 229,
260, 269
principle ethics 65
principles-oriented (top-down)
decision making 23–6
Prochaska, J.O. and DiClemente, C.C.
154–3
professional ethics 17–19, 37, 44, 126–3,
244–67,
see also codes of ethics
Protestant Reformation 101
psychic significance of values 79
psychoanalytic psychologists 207
psychogenetics 103
psychologists, disputes with
psychiatrists 130;
extra-scientific values 116–4
psychotherapists, accountability 139–7;
“directive” 175;
dual commitment 247–8;
ethical convictions 40, 44, 48, 52, 55,
173;
ethical reflection 39–2, 44, 47, 132,
184, 271–2;
as ethicists 15, 31, 32–45, 47;
influence on others 10, 40–5;
as priests 230, 235;
relationship with client 22, 126–3,
143, 156, 162–1, 241;
self-awareness 10–11, 47, 48, 253–4;
and self-interest 134, 135–3;
tightly delineated role 235–6;
virtues 65, 153–1, 170, 173,
see also professional ethics
psychotherapy, analysing effectiveness
26, 145, 182;
contexts 101–30;
ethical alternatives 267–81;
ethical dimensions/character 126,
265–6;
history of 106–17;
inherited ideas 124;
medical heritage 124–8;
Old/New 106–14;
processes 148–87;
role of science 7–9, 110–30;
in society 47–3, 222–53;
traditional role 224–5;
unlimited access 27, 51–6, 59, 68–4,
132–40, 134, 135;
value-free/value-laden 5–7, 10–12,
77, 104, 150, 224, 244, 260,
see also theoretical ethics;
therapeutic goals;
therapeutic outcomes;
therapy process
public philosophy 222–51,
see also therapeutic contracts
radical psychologists 270
Ramsey, P. 158
rational ethics 270, 272
Rational-Emotive therapy (RET) 51, 69,
208
Rawls, J. 109, 234, 236
Reality Therapists 173, 205
reason, and ethical knowledge 70, 71
redemptive suffering 194–2, 206, 207
reevaluation, as change process 155
Regier, D.A., Narrow, W.E., Rae, D.S.,
Manderscheid, R.W., Locke, B.Z. and
Goodwin, F.K. 139
regulatory/policy ethics 26
Reich, Wilhelm 18, 103, 126
relativism 54–57, 61, 185, 232–3, 255;
and neutrality 170, 171, 172
relativism/absolutism 54–57;
middle ground 55–57, 186, 193, 197,
199
religion, concepts of goodness 211, 213;
and ethics 47, 63–8, 72–76, 236–7,
270;
fundamentalism, 233–4;
and informed consent 160;
and neurosis 51;
and psychotherapy 61, 229–41;
and public philosphy 230
Rescher, N. 95, 165, 206, 219
INDEX 329
Rest, J.R. 265, 273
revaluation of values see transvaluation
Richardson, F.C. 55, 161–70
Richardson, F.C. and Fowers, B.J. 186,
268
Richardson, F.C. and Woolfolk, R.L. 74,
156, 271
Ricoeur, P. 269
Rieff, P. 33–7, 207
Roazen, P. 194
Robinson, D.N. 107, 266
Rogerians 59, 61
Rogers, Carl, humanistic psychology
49, 56, 62–7, 82–8, 90, 212;
non-directive approach 226;
obligation 103;
therapeutic goals 169, 179
Rokeach, M. 7, 31–4, 79, 81, 114, 116
Roman Catholic ethics 63
Romanticism 72, 90, 91, 208–17, 270
Rorty, A.O. 270
Rosenau, P.M. 56
Rosenberg, C. 132–40
Rosenthal, D. 96
Rosenthal, P. 94
Ruddick, W. and Finn, W. 39
Sadler, J.Z. and Hulgus, Y.F. 121–9, 264
Salmon, J.W. 141
Sarason, S.B. 127
Sartre, J.-P. 82
Sass, H.M. 140–8
Sass, L.A. 74, 101, 263, 271, 276
“Scale of Values” 89
Schacht, R. 84, 88
Schimmel, S. 211–20
Schofield, W. 129
Schwartz, B. 66, 83, 109
Schwartz, S.H. 83
Schwartz, S.H. and Bilsky, W. 62, 92,
93
Schwehn, J. and Schau, C.G. 165
science and ethics 28–1, 70–6, 105–30;
evaluating therapy ideals 215;
extra-scientific values 114, 115,
116–6;
and goodness 119–8;
history of 106–17, 112;
measuring therapeutic
effectiveness 231;
parsimony 113, 265;
science alone 111–21, 120;
skepticism 112–20;
values intrinsic to 114–3, 119, 123
scientism 116, 117, 122;
de facto 111, 112, 113;
paradox 118;
philosophical 111–19
Seiden, A. 213
self-actualization 64, 128, 192, 194, 212,
214;
distinct from selfishness 209;
as goal 2, 189, 208, 219;
humanistic psychologists 45, 82, 90
self-enhancement v. self-sacrifice
208–17
self-fulfillment 208, 216, 237
self-liberation, as change process 155
self-realization see self-actualization
selfishness 206, 209–18, 227
Seligman, C. and Katz, A.N. 92
Sensenig, A.L., Heffler, S.K. and
Donham, C.S. 141
Sexton, V.S. 107
Shafranske, E.P. and Malony, H.N. 76
Shapiro, D.A., Harper, H., Startup, M.,
Reynolds, S., Bird, D. and Suokas, A.
154
Sherwin, S. 62, 101
short-term outcome 203–11
Shotter, J. 55
Shweder, R.A. 56
skepticism 113, 185,
see also postmodernists
Skinner, B.F. 79, 79, 81, 108, 117, 203
Skolimowski, H.K. 115
Slote, M. 15
Smith, M.B. 193, 209, 234, 260
social contract see therapeutic contract
social ethics 19, 25–28, 37, 44
social policy see public philosophy
society v.individual wellbeing 209–18,
226–8, 247, 261, 263, 270
sociobiology 67, 71, 269–80
Socrates 128, 194, 274
330 ETHICS AND VALUES IN PSYCHOTHERAPY
sources of ethical ideas 275–6
spirituality, in therapeutic process 75–1
Spranger, E. 89–6
stakeholders, accountability of
psychotherapists 48;
criteria 144–2;
different interests 4, 202–10
Steininger, M. 117
Stiles, W.B. 189
Stiles, W.B., Shapiro, D.A. and
Barkham, M. 4
Stiles, W.B., Shapiro, D.A. and Elliott,
R. 190, 201, 208
Stiles, W.B., Shapiro, D.A. and Harper,
H. 151, 156
Stoics 206
stories, interpreting see hermeneutics
Strenger, C. and Omer, H. 270
Strupp, H.H. 2, 4, 5, 6, 91, 129, 191–9,
196, 210, 231
Strupp, H.H. and Hadley, S.W. 189,
212
Suan, L.V. and Tyler, J.D. 192, 211
Sullivan, W.M., 248
Szasz, T.S. 128, 179, 207
Taylor, C., ethical articulacy 237, 274;
ethical theory 61, 74, 83–84, 86,
93, 214, 215, 260, 263, 267–8, 270;
good ends 188;
modern identity 101, 105, 117, 225,
229;
obligation 184, 187;
professional ethics 254, 257;
reason 264, 266;
scientism 111;
self-centredness 216–5, 218–7;
self-reflection 213
teleological/consequentialist ethical
theories 64–65, 110, 120, 121, 152, 173
theoretical ethics 19, 19–3, 24, 44, 47–77
therapeutic contracts 225, 241–3, 248
therapeutic goals 2–4, 180–219;
behaviour change 2, 165, 208;
choosing 6, 136, 179, 261;
client’s own 5–7, 40, 187, 211;
conflicts 22–5;
consensus 5, 179, 183–1, 200;
covert 185;
level of abstraction 199–7;
Rational Emotive Therapy 208;
social element 209–19, 216;
tailored/universal 200–8,
see also ethical ideals;
therapy process
therapeutic outcomes 97, 182–90,
185–4, 189, 203–11, 206, 213;
and therapy process 150–8, 152,
154, 161, 162, 179, 180–219
therapy ideals, and ethical theory
214–3;
multiple 215–7
therapy process 148–87;
appropriate/inappropriate 167–87;
ethically evaluated 155–4, 261;
and ethics 150–69,
see also autonomy;
context;
therapeutic outcomes
Theravada Buddhism 76
third parties 133–4;
agreements 158;
obligations 59;
payers 6, 27, 202, 204–12, 225, 235,
242;
role of 53, 179
Tillich, P. 228
Tjeltveit, A.C., Fiordalisi, A.M. and
Smith, C. 192
Tolman, Edward C. 116
Toulmin, S.E. 114
Toulmin, S.E. and Leary, D.E. 53, 70,
107
Trabin, T. and Freeman, M.A. 138, 144,
228
tradition, and ethical knowledge 69–5
transdisciplinary moral psychology 49
transference, 159
“transvaluation of values” (Nietzsche)
87, 89
Tyler, J.D., Clark, J.A., Olson, D., Klapp,
D.A. and Cheloha, R.S. 206
US Federal Trade Commission 18
INDEX 331
US National Institute of Mental Health
110
utilitarianism 66, 67, 206
Vachon, D.O. and Agresti, A.A. 254
value theorists 84–1, 89, 90, 91
values 2, 5, 77–98;
clarification 173–2;
of clients 5, 37, 47–2, 254;
in context 91–9;
cross-cultural perspectives 4–5, 28,
54, 201, 233;
different stakeholders 4, 5, 48, 52–7,
68, 189;
empirical investigation 7–9, 11, 12,
31, 89–6, 91, 92;
fact/value dualism 84;
fundamental 105;
imposed by powerful 82, 89, 96,
102;
left wing 270;
mental health 59, 97–4;
moral-nonmoral conflict 59–4, 198;
multiple meanings of 79–96;
need for scrutiny 5, 11;
relationships between 92;
Spranger’s six types 89;
and truth 8–9;
universal 83,
see also goodness;
theoretical ethics
VandenBos, G.R., Cummings, N.A. and
DeLeon, P.H. 136–4
Varma, V.K. 4, 201
Veatch, R.M. 18, 24, 33, 127, 203, 217,
243, 248
virtue ethics 19, 24–7, 27, 44, 65, 189,
271
virtues 212–2, 250;
monistic v. multivalent theories
219;
Thomas Aquinas 73
Vitz, P.C. 74
Wakefield, J.C. 194, 195
Wallace, R.R. 41, 103, 131, 172, 197, 210,
217, 230–1, 245, 249
Wallach, M.A. and Wallach, L. 62, 66,
67, 218–7
Wallerstein, R.S. 166
Waterman, A.S. 109–17, 116, 120
Watson, J.B. 112, 117
Weisskopf-Joelson, E. 165
Wendorf, D.J. and Wendorf R.J. 178
Western Electric 136
“wide reflective inquiry” 24
Williams, A. 135, 141
Williams, R.M. 165
wisdom, 253, 272
Witmer, Lightner 107
Wolfe, B.E. 165, 174, 189, 205, 213, 216
Woodworth, R.S. 130
World Health Organization 196
Worthington, E.L. Jr 216
Wundt, Wilhelm 106, 121